<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423935
Report Date: 01/31/2024
Date Signed: 01/31/2024 11:13:14 AM

Document Has Been Signed on 01/31/2024 11:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, LLCFACILITY NUMBER:
366423935
ADMINISTRATOR:CAPILI, IRENEFACILITY TYPE:
735
ADDRESS:302 NORDINA ST.TELEPHONE:
(909) 798-2876
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY: 41CENSUS: 35DATE:
01/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Irene CapiliTIME COMPLETED:
11:20 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/31/2024, Licensing Program Analyst (LPA) Melody Brown arrived at the facility to initiate a Case Management - Deficiency. LPA Brown met with Managing Member Florsefina Negado and Administrator Irene Capili. LPA Brown explained the purpose of the visit to Administrator Irene Capili.

During the visit on 01/26/2024, LPA Brown reviewed Client #1 (C1) facility documents and observed that the facility did not update C1 Needs and Services Plan as required. Per documents review, C1 completed Needs and Services Plan (LIC625) date's 01/09/2020 and C1 Physician Report (LIC602) date 01/15/2016. Administrator Capili was informed that LPA Brown will issue a deficiency as this pose potential health, safety and personal rights risks to clients in care.

An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Administrator Irene Capili.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/31/2024 11:13 AM - It Cannot Be Edited


Created By: Melody Brown On 01/31/2024 at 10:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/29/2024
Section Cited
CCR
85068.3(a)

1
2
3
4
5
6
7
85068.3 Modifications to Needs and Services Plan (a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental...This requirement is not met as evidenced by:

1
2
3
4
5
6
7
Licensee stated to train all staff on CCR 85068.3(a) and submit proof of all staff training log to LPA Brown at Plan of Correction (POC) due date.
8
9
10
11
12
13
14
Based on observation, interview and records review, the Licensee did not comply with the section cited above by not updating the required Needs and Services Plan for C1 and no updated Physician Report for C1 which pose potential health, safety and personal rights risks to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2