198602600-5-26-2026-28-AS-DKOI-DUFQSH-20260526122535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602600
Report Date: 05/26/2026
Date Signed: 05/26/2026 12:26:28 PM

Document Has Been Signed on 05/26/2026 12:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GOOD SHEPHERD COTTAGE ASSISTED LIVING		FACILITY NUMBER:	198602600
ADMINISTRATOR/ DIRECTOR:	KLIEN,KATHRYN		FACILITY TYPE:	740
ADDRESS:	1218 ROYAL OAKS DR		TELEPHONE:	(626) 239-0710
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY: 28		CENSUS: 19	DATE:	05/26/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:58 AM
MET WITH:	Gabrielle McDonald, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:35 PM

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with the Administrator, Gabrielle McDonald and LPA explained the purpose of the visit. There are currently (18) elderly residents 60 years and older residing in the facility. Facility is licensed to care for elderly residents age range 60 and over, 28 ambulatory, of which 28 may be non-ambulatory, hospice waiver for 7.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has s Infection Control Plan in file. Staff are adhering to infection control requirements.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Hospice Waiver for seven (7) is approved. A fire clearance is in place. Fire Drill was last conducted on 5/22/2026. Valid Liability Insurance is in file.

Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor: reception area, living room with covered fireplace, dining area, (11) resident bedrooms, administration office, break room, nurses/medication room, kitchen, storage room, laundry room, conference room and outdoor seating/patio areas. Second floor: (11) resident bedrooms, living room with covered fireplace, Food storage room, Electrical room, Break room, Housekeeping room,

[Continue LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOOD SHEPHERD COTTAGE ASSISTED LIVING	FACILITY NUMBER: 198602600
	VISIT DATE: 05/26/2026

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Physical Plant/Environment Safety [Cont.]: elevator/telephone/data room, and laundry room. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathroom has non-skid materials and contained hygiene supplies including liquid soap, paper towel and toilet paper. There is a fireplace in the living room in each floor that is secured and fully covered. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to residents. There are (9) fire extinguishers observed in the entire facility that were fully charged and serviced on 05/21/2026. Evacuation Chairs are located by the stairways. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operational and compliant. LPA tested hot water temperature in eight (8) random resident rooms and measured between 112.1 degrees F to 114.8 degrees F which is within Title 22 regulations.

Staffing: Facility has a sufficient staffing to provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility.

Personnel Records/Staff Training: LPA reviewed the Administrator and four (4) staff files that included Personnel Record, Health Screenings, fingerprint clearances, Employee Rights, Valid Food Handler’s Certificate, Medication Administration Training, Ongoing Staff Training, and Valid First Aid/CPR/AED training. Administrator certificate is valid and will expire on 1/25/2028.

Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the 1st floor. Resident personal rights are posted. Notice of visiting policy is posted. Per staff, facility provides internet services to all residents and they have access to the facility phone.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Activities calendar is up to date and posted near the dining area. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be using disposable gloves while working.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOOD SHEPHERD COTTAGE ASSISTED LIVING	FACILITY NUMBER: 198602600
	VISIT DATE: 05/26/2026

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Incidental Medical and Dental: LPA reviewed Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. LPA observed the First Aid Kit that has all required items.

Resident Records/Incident Reports: LPA reviewed five (5) resident files that included the Face Sheet, Admission Agreements, Physician's Reports, Ambulatory Status, TB Clearance, Preplacement Appraisal, Appraisal/Needs and Services Plan, Safeguards for Property/Valuables, and Personal Rights.

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills.

Residents with Special Health Needs: Per Administrator, no resident receives hospice care and there are no bedridden residents.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit interview was held and a copy of this report was provided to the Administrator, Gabrielle McDonald.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

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