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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700562
Report Date: 06/18/2024
Date Signed: 06/18/2024 12:04:14 PM

Document Has Been Signed on 06/18/2024 12:04 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOOD SHEPHERD VILLAFACILITY NUMBER:
502700562
ADMINISTRATOR/
DIRECTOR:		KOESTER, EULERINAFACILITY TYPE:
735
ADDRESS:1909 LIFETIME DRIVETELEPHONE:
(209) 567-2065
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 3DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Eulerina KoesterTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 06/18/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Eulerina Koester and explained the purpose of the visit. There was one other staff member present, Maribel Castillo.
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 3. 3 out of 3 residents were out at their respective day programs at the time of the visit.
At 10:00am, LPA reviewed 3 resident files. 3 out of 3 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 does not have a current administrator certificate, however, LPA has reviewed and verified that the FDA has sent in the proper paperwork to the department prior to the certificates expiration date and is awaiting for department review.

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 12/01/2024. Carbon monoxide and smoke detectors were in good repair.
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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOOD SHEPHERD VILLA
FACILITY NUMBER: 502700562
VISIT DATE: 06/18/2024
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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 610e

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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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