502700562-5-2-2023-27-AS-APAA-CRFKZ4-20230502082004

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700562
Report Date: 05/01/2023
Date Signed: 05/02/2023 08:20:36 AM

Document Has Been Signed on 05/02/2023 08:20 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:	05/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Eulerina Koester		TIME COMPLETED:	12:00 PM

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	On 05/01/2023 at 9:45am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual visit. LPA was greeted by Staff Member(SM), Maribel Castillo and explained the purpose of the visit. LPA asked SM Castillo to call the Facility Designated Administrator (FDA) to inform them that CCL was present at this time. Shortly after, LPA met with FDA Eulerina Koester. This facility is licensed to serve and retain up to 6 residents at this time. This facility is also vendorized by Valley Mountain Regional Center to hold and accept Level 3 residents at this time. Current Census was 4. 3 out of 4 residents were out at their respective day programs at the time of the visit. At 10:00am, LPA reviewed 4 resident files. 4 out of 4 resident files were current and up to date. LPA reviewed 4 staff files. 4 out of 4 staff files were current and up to date. The FDA has a current and active administrator certificate #6015534735 and expires on 05/20/2024. At 11:00am, LPA iniatied a tour with FDA Koester. 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 12/07/2023. The kitchen area was toured. LPA 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. LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA 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.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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: 05/01/2023

NARRATIVE

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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.

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 was conducted and copy of this report was provided to the facility at the end of this visit.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

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