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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423935
Report Date: 06/22/2023
Date Signed: 06/22/2023 11:03:33 AM

Document Has Been Signed on 06/22/2023 11:03 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: 36DATE:
06/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Irene Capili-AdministratorTIME COMPLETED:
11:15 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) Bernadette Allen conducted an unannounced visit to the facility to conduct a case management visit and follow up on an adult client death. LPA Allen met with Irene Capili who was informed of the purpose of the visit.

This case management visit consisted of collecting pertinent documentation and conducting staff and residents interviews regarding the death of Client #1(C1). LPA Allen interviewed the administrator, client #2 (C2) and client #3 (C3) for further information regarding the death of (C1) and the events that led up to (C1's) death.

Irene Capili stated that there is no official death certificate or cause of death at this time. LPA Allen has advised the administrator to send a copy of the death certificate to Community Care Licensing Division (CCLD) Riverside Regional Office as soon as it is available.

LPA toured the facility inside and out and there was no imminent health and/or safety concerns observed at the time of visit

An exit interview was conducted where this report was discussed with Irene Capili and a copy was provided at the conclusion of the visit..

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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