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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366423935
Report Date: 01/22/2024
Date Signed: 01/22/2024 04:35:11 PM

Document Has Been Signed on 01/22/2024 04:35 PM - 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: 36DATE:
01/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Irene Capili, AdministratorTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Irene Capili, Administrator, and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), license capacity of (41) with a current census of (36). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to clients in care. The facility is maintained at a comfortable temperature. Client bathrooms were inspected at random. The hot water temperature in clients' bathrooms measured 105 to 108 degrees F. The facility's upstairs central bathroom located near bedroom 206 was not operating properly, the faucet handle used to operate the shower was missing. The facility's downstairs hallway leading to central bathroom near bedroom 103, was not well lit and did not have a night light. Client bedrooms have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen, towels, and personal hygiene items for clients. The facility has posted in a common area, Community Care Licensing complaint poster, facility license, disaster evacuation plan and emergency telephone numbers.


Food Service: Facility has sufficient non-perishable and perishable food supply for clients in care. Pesticides and other cleaning solutions were kept locked and stored away from food areas.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, LLC
FACILITY NUMBER: 366423935
VISIT DATE: 01/22/2024
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Care & Supervision: Facility has 24-hour, 7 days a week care staff. Staff working have criminal record clearances or exemptions through the Department.

Record Review: Staff files reviewed were observed to be complete. Client files reviewed were observed to be complete. Administrator’s certification expires on 11/12/24.

Medical Related Services: Facility has complete first aid kits with manuals. All medication is centrally stored and kept locked in the medication room.

Based on LPA observations, deficiencies were cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where reports LIC809, LIC809-C, LIC809-D and LIC9102 were discussed and copies with Appeal Rights were provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2024 04:35 PM - It Cannot Be Edited


Created By: Magda Malcore On 01/22/2024 at 03:34 PM
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
RIVERSIDE, CA 92507

FACILITY NAME: GOOD SHEPHERD MANOR, LLC
FACILITY NUMBER: 366423935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by central bathroom located near bedroom 206 was not operating properly, the faucet handle was missing, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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The licensee shall submit to the licensing agency proof of fixed shower faucet by POC due date.
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by hallway leading to central bathroom near bedroom 103, was not well lit and did not have a night light, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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The licensee shall submit to the licensing agency proof of proper lighting by POC due date.
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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024


LIC809 (FAS) - (06/04)
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