502700562-6-9-2022-27-AS-APAA-CF8LGK-20220609084451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700562
Report Date: 06/08/2022
Date Signed: 06/09/2022 08:45:01 AM

Document Has Been Signed on 06/09/2022 08:45 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GOOD SHEPHERD VILLA		FACILITY NUMBER:	502700562
ADMINISTRATOR:	KOESTER, EULERINA		FACILITY TYPE:	735
ADDRESS:	1909 LIFETIME DRIVE		TELEPHONE:	(209) 567-2065
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY: 6		CENSUS: 4	DATE:	06/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Eulerina Koester		TIME COMPLETED:	12:30 PM

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Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua conducted an unannounced required-1 Year inspection visit on 06/08/2022. LPAs met with the facility designated Administrator, Eulerina Koester. It was observed that the administration certificate for Eulerina Koester was due to expire on 05/20/2024. There was one other staff member present, Maribel Castillo.

The current census was 4 residents.

A tour of this facility was conducted.

The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Cal State Fire and was valid until 12/14/2022.

The kitchen area was toured. LPAs observed a sufficient seven days of non-perishable foods as well as two days worth of perishable food supplies in the main kitchen. Additional perishable and non-perishable food supplies were identified in the garage.

LPAs observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPAs observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GOOD SHEPHERD VILLA	FACILITY NUMBER: 502700562
	VISIT DATE: 06/08/2022

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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional non-perishable food supplies were identified. Additional storage for supplies and files were stored in cabinets. All cleaning supplies were locked and made inaccessible to residents at this time.

The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

No deficiencies were observed or cited during this annual visit.

Exit interview.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC809 (FAS) - (06/04)

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