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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423935
Report Date: 01/12/2024
Date Signed: 01/12/2024 10:15:24 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/08/2024 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240108150621
FACILITY NAME:GOOD SHEPHERD MANOR, LLCFACILITY NUMBER:
366423935
ADMINISTRATOR:CAPILI, IRENEFACILITY TYPE:
735
ADDRESS:302 NORDINA ST.TELEPHONE:
(909) 798-2876
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:41CENSUS: 37DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:TIME COMPLETED:
10:19 AM
ALLEGATION(S):
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Facility bedroom door is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility for the purpose of initiating the investigation of and delivering findings for the above allegations. LPA met with facility staff Christine and Flora Medina-Negado who was advised of the purpose of visit. The investigation consisted of inspection of the physical plant and interviews with relevant parties.

It is alleged that the Facility bedroom door is in disrepair. During the tour of the facility, LPA and staff Christine observed the closed door to room112 with a broken latch. The door is observed with a doorknobu but without a latch.The front part of the door facing the hallway, is missing wood around the lock area, allowing light from inside the room to come through the door. This allegation is therefore substantiated.This poses a potential health and safety risk to residents in care.

A finding that the complaint is SUBSTANTIATED means that the allegations are valid as the preponderance of the evidence standard has been met. Refer to LIC809-D for deficiency cited. A technical violation is issued for physical plant issues discoverd during today's visit. An exit interview was conducted where this report, LIC809-D, and appeal rights were provided to Christine Medina-Negado.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20240108150621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GOOD SHEPHERD MANOR, LLC
FACILITY NUMBER: 366423935
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
80087(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by
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Licensee shall repair the bedroom door so as to ensure that the door with latch to the doorjamb and close.
Licensee shall submit proof of correction no later than end of day of POC date.
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Facility staff and LPA observed room 112 door to be broken with missing wood around the lock area and without a latch. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2