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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423935
Report Date: 01/31/2024
Date Signed: 01/31/2024 11:11:14 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
01/25/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240125092950
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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Irene Capili and Managing Member Florsefina NegadoTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff did not ensure client's dental needs were met.
Staff did not safeguard client’s personal belongings.
INVESTIGATION FINDINGS:
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On 01/31/2024 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown arrived at the facility to deliver the findings for the above complaint allegations. Upon arrival, LPA Brown met with Managing Member Florsefina Negado, and conducted additional interview. Administrator Irene Capili was informed of the visit and arrived during the visit. LPA Brown explained the purpose of the visit to Administrator Irene Capili.

The investigation consisted of file review, observations and interviews with relevant parties. LPA Brown toured the facility, conducted interviews, and reviewed facility files. The allegation indicates Staff did not ensure client's dental needs were met. LPA Brown obtained evidence to corroborate the allegation listed above. During the visit on 01/26/2024, LPA Brown conducted interviews with clients and staffs. Four (4) out of Six (6) clients interviewed reported that staff did not ensure their dental needs were met. LPA Brown unable to interview C1 due to C1 moved out of the facility on 07/27/2023.
*** Continuation in LIC9099C ***
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 56-AS-20240125092950
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
VISIT DATE: 01/31/2024
NARRATIVE
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Three (3) out of three (3) staffs interviewed reported that they ensure that their clients' dental needs were met however, when LPA Brown asked Staff #1 when were the clients at the facility last seen by a dentist and also requested for the dentist contact information, S1 did not provide the requested information to LPA Brown during the visit on 01/26/2024.

The second allegation indicates that Staff did not safeguard client’s personal belongings. LPA Brown obtained evidence to corroborate the allegation above. Through the information gathered during the investigation, it was confirmed by observations and interviews that staff are not safeguarding clients' personal belongings at the facility. Four (4) out of Six (6) clients interviewed reported that staff did safeguard their personal belongings. Three (3) out of three (3) staffs interviewed reported that they are safeguarding their clients personal belongings. S1 reported to LPA Brown "If something is missing, they must come to us and we will try to recover it." During the visit on 01/26/2024, LPA Brown reviewed documents and observed that the facility does not have a Theft and Loss Policy. During the visit on 01/31/2024, S3 confirmed no Theft and Loss Policy at the facility.

Based on LPA Brown's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore, the allegation of Staff did not ensure client's dental needs were met (Allegation #1), Staff did not safeguard client’s personal belongings (Allegation #2) are SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 is being cited on the attached LIC9099D.

An exit interview was conducted where this report (LIC9099), LIC9099D 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20240125092950
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: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/29/2024
Section Cited
CCR
85075(b)
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85075 Health-Related Services (b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement is not met as evidenced by:
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Licensee stated to develop and implement a plan to ensure that assistance is provided to clients in meeting their dental needs and submit copy to LPA Brown at Plan of Correction (POC) due date.
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Based on interview, observations and records review, the Licensee did not comply with the section cited above by not assisting 4 of 6 clients on their dental needs and not ensuring that their dental needs are met which pose potential health, safety and personal rights risks to clients in care.
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Type B
02/29/2024
Section Cited
CCR
80026(b)
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (b) If such a client is accepted for or maintained in care, his/her cash resources, personal property, and valuables not handled by a person outside the facility who has been designated by the client or his/her authorized representative shall be handled by the licensee or facility staff, and shall be safeguarded in accordance with the requirements...This requirement is not met as evidenced by:
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Licensee stated to develop a plan on how to safeguard clients personal property, belongings and submit proof to LPA Brown at POC due date.
Licensee stated to train all staff on CCR 80026(b) and submit proof of Training Log to LPA Brown at POC due date.
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Based on interview, observations and records review, the Licensee did not comply with the section cited above by not safeguarding 4 of 6 clients personal belongings at the facility which pose potential health, safety and personal rights risks to clients 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: 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
01/25/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240125092950

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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Managing Member Florsefina Negado and Administrator Irene CapiliTIME COMPLETED:
11:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure client's medical needs were met.
Staff did not assist client with grooming.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/31/2024 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown arrived at the facility to deliver the findings for the above complaint allegations. Upon arrival, LPA Brown met with Managing Member Florsefina Negado and conducted additional interview. Managing Member Negado contacted Administrator Irene Capili and Administrator Capili arrived during the visit.

The investigation consisted of file review, observations and interviews with relevant parties. LPA Brown toured the facility, conducted interviews, and reviewed facility files. The allegation indicates Staff did not ensure client's medical needs were met. During the investigation, LPA Brown did not find evidence to corroborate the allegation. During the visit on 01/26/2024, interviews with clients indicated that staffs at the facility ensure that their medical needs were met. Staffs interviews indicated that they are ensuring that thier clients' medical needs were met. Client and Staff interviews revealed that a doctor visits the facility monthly to check on clients at the facility.
**Continuation in LIC9099C***
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20240125092950
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
VISIT DATE: 01/31/2024
NARRATIVE
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On 01/31/2024, LPA Brown contacted C1's doctor's office and per documents review, C1 was last seen by C1's doctor on 07/10/2023. In addition, doctor's office staff reported to LPA Brown that no indication of cataract observed during the visit on 07/10/2023.

The second allegation indicates that Staff did not assist client with grooming. During the investigation, LPA Brown did not find evidence to corroborate the allegation. During the visit on 01/26/2024, interviews with clients indicated that staffs at the facility are assisting them with their grooming. Interviews with staffs indicated that they are assisting all their clients with their grooming at the facility. Clients interviews revealed that the facility's providing haircut to all the clients at the facility.

Based on the evidence, the allegation that Staff did not ensure client's medical needs were met (Allegation #1) and Staff did not assist client with grooming (Allegation #2) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.



An exit interview was conducted where this report, LIC9099 was 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5