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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423935
Report Date: 04/18/2023
Date Signed: 04/18/2023 09:43:15 AM

Document Has Been Signed on 04/18/2023 09:43 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: 37DATE:
04/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Irene CapiliTIME COMPLETED:
10:00 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
Licensing Program Analysts (LPA) Paola Guerrero conducted an unannounced visit to the facility the purpose of the visit was to initiate an annual inspection due to technical issues a Case Management visit Health & Safety check visit was initiated. LPA Guerrero identified herself to Irene Capili and discussed the purpose of the visit. Clients in care were present during visit. No imminent health and/or safety concerns observed at the time of visit. LPA Guerrero observed no health and/or safety hazards inside the facility. LPA Guerrero inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Guerrero observed sufficient staff present at the facility to provide care. LPA Guerrero inspected facility food supplies and observed three (3) day supply of perishable and seven days (7) supply of non-perishable food. The needs of the residents in care appear to be met during this inspection. LPA will return to facility to initiate annual inspection visit.

An exit interview was conducted where this report (LIC809) was discussed and provided to Irene Capili.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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 1