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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366423935
Report Date: 01/10/2022
Date Signed: 01/10/2022 01:04:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2021 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210218171137
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: 40DATE:
01/10/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Irene CapiliTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility retaliating against resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA Williams identified herself to the Administrator, Irene Capili, who was also informed of the purpose of the visit. The investigation consisted of records review and interviews with staff and residents.

LPA Williams interviewed Staff #1 (S1) who denied that facility staff is retaliating against Client #1 (C1). S1 stated that C1 was given an eviction notice in February 2019 for substance abuse which facility believe to be the cause of C1's paranoia and aggressive behavior. LPA Williams also interviewed Client #2 (C2), who used to be C1's roommate. C2 stated that C1 was unstable and asked to be moved into another room due to fear of C1's behaviors and paranoia. LPA Williams interviewed the Administrator of C1's previous facility, who indicated that C1 was relocated due to substance abuse which was believed to be the cause of C1's aggressive and accusatory behaviors. LPA Williams also interviewed Psychologist #1 (P1), who stated that C1 would make numerous false allegations against the facility. P1 stated that they "absolutely" do not believe that
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20210218171137
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOOD SHEPHERD MANOR, LLC
FACILITY NUMBER: 366423935
VISIT DATE: 01/10/2022
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
26
27
28
29
30
31
32
facility staff are retaliating against C1 by stalking C1, being verbally/physically abusive to C1, or trying to kill C1. P1 stated that C1 was unstable as C1 had substance abuse issues which heightened C1's diagnosis of psychosis and paranoia.

Based on evidence obtained during today’s visit, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2