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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606836
Report Date: 09/11/2026
Date Signed: 09/11/2026 04:11:33 PM

Document Has Been Signed on 09/11/2026 04:11 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GOOD SHEPHERD HOMEFACILITY NUMBER:
197606836
ADMINISTRATOR/
DIRECTOR:		FEDELITO RUIZFACILITY TYPE:
740
ADDRESS:14812 LA FONDA DRIVETELEPHONE:
(714) 739-1182
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 6DATE:
09/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:32 PM
MET WITH:Fedelito Ruiz, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Administrator Fedelito Ruiz.The facility is licensed as a Residential Care for the Elderly (RCFE) that serves developmentally disabled residents ages 59 and over vendored by Eastern Los Angeles Regional Center. Administrator certificate expires 1/29/2027.

Infection Control: The facility has an Infection Control Plan that is reviewed annually.

Operational Requirements: A hospice waiver for 1 resident is in place. Fire clearance is approved for 6 non-ambulatory residents. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current and expires 7/1/2027. The facility handles resident P & I monies. However, licensee does not have a Surety Bond in place. *Citation was issued.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood. There are 4 resident bedrooms, and 2 live-in staff rooms, living room, office, kitchen, 3 bathrooms, backyard and front yard patio areas, and attached garage with laundry area. All bedrooms are equipped with required furniture, bedding, mattress pad, and lighting. Cleaning supplies, knives, and toxic substances are inaccessible to residents. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and manual. The facility has two (2) fire extinguishers. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility is equipped with a sprinkler system and smoke/carbon monoxide detectors. The last fire inspection was conducted on 12/23/2024 by County of Los Angeles Fire Department.

*NOTE: The dining room is now used as an office. Administrator will submit an updated facility sketch.

Staffing: A total of 5 staff members provide care and supervision to the clients.

Lisa Hicks
Noemi Galarza
DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GOOD SHEPHERD HOME
FACILITY NUMBER: 197606836
VISIT DATE: 09/11/2026
NARRATIVE
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Personnel Records/Staff Training: Four (4) staff files were reviewed. Criminal background clearance, staff training, health screening & TB clearance, DSP, 1st Aid/CPR, and, CEU's are on file.

Resident Records/Incident Reports: Six (6) resident files were reviewed. Admission agreements, Physician's Report, HCBS Tenant/Landlord Agreements, medical/functional assessments, ISP's & Functional Behavior Assessment, TB clearance, IPP reports, personal rights, medical consent, consultant logs, P & I records, and Medication Administration Records were reviewed. Personal & Incidental (P & I) monies/records were reviewed.

RCFE and Ombudsman complaint posters are posted. A technical advisory was issued because the RCFE poster is not the correct size.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council.

Food Service: Food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Three residents require modified diets.

Incident Medical and Dental: Residents are assisted with self administration of prescription and non-prescription medications. The medications are centrally stored and in their original containers. The facility uses a Medication Administration Record (MAR) log. Centrally stored resident medication records were reviewed and are given according to Physician directions. 30-Day supply of medications were reviewed. Medical and dental transportation is provided by the facility.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual.

Residents with Special Health Needs: Currently there are no residents enrolled in hospice or home health care. No residents have prohibited health conditions. All residents require adaptive equipment.

Disaster Preparedness, and Emergency Intervention: Emergency Disaster Plan was reviewed. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. First Aid Kit and Manual were observed. The last Emergency Disaster drill was conducted on 8/1/2026.

Emergency Intervention: De-escalation techniques are not used at the facility.

Pursuant to Title 22, a deficiency was cited. A technical advisory was issued.

Exit interview was conducted with Administrator Fedelito Ruiz. A copy of the report/appeal rights was issued.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 04:11 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/11/2026 at 02:39 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOOD SHEPHERD HOME
FACILITY NUMBER: 197606836

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2026
Section Cited
CCR
87216(a)

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Bonding. (a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.
This requirement is not met as evidenced by
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Licensee shall obtain a Surety Bond with the an amount sufficient to adequately protect the money of residents.
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Based on record review, the licensee did not comply with the section cited above because P & I monies are handled and there is no Surety Bond in place, which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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