Good Shepherd Cottage Assisted Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with the Administrator, Gabrielle McDonald and LPA explained the purpose of the visit. There are currently (18) elderly residents 60 years and older residing in the facility. Facility is licensed to care for elderly residents age range 60 and over, 28 ambulatory, of which 28 may be non-ambulatory, hospice waiver for 7. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has s Infection Control Plan in file. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Hospice Waiver for seven (7) is approved. A fire clearance is in place. Fire Drill was last conducted on 5/22/2026. Valid Liability Insurance is in file. Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor: reception area, living room with covered fireplace, dining area, (11) resident bedrooms, administration office, break room, nurses/medication room, kitchen, storage room, laundry room, conference room and outdoor seating/patio areas. Second floor: (11) resident bedrooms, living room with covered fireplace, Food storage room, Electrical room, Break room, Housekeeping room, [Continue LIC809-C] Physical Plant/Environment Safety [Cont.]: elevator/telephone/data room, and laundry room. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathroom has non-skid materials and contained hygiene supplies including liquid soap, paper towel and toilet paper. There is a fireplace in the living room in each floor that is secured and fully covered. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to residents. There are (9) fire extinguishers observed in the entire facility that were fully charged and serviced on 05/21/2026. Evacuation Chairs are located by the stairways. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operational and compliant. LPA tested hot water temperature in eight (8) random resident rooms and measured between 112.1 degrees F to 114.8 degrees F which is within Title 22 regulations. Staffing: Facility has a sufficient staffing to provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility. Personnel Records/Staff Training: LPA reviewed the Administrator and four (4) staff files that included Personnel Record, Health Screenings, fingerprint clearances, Employee Rights, Valid Food Handler’s Certificate, Medication Administration Training, Ongoing Staff Training, and Valid First Aid/CPR/AED training. Administrator certificate is valid and will expire on 1/25/2028. Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the 1st floor. Resident personal rights are posted. Notice of visiting policy is posted. Per staff, facility provides internet services to all residents and they have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Activities calendar is up to date and posted near the dining area. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be using disposable gloves while working. Incidental Medical and Dental: LPA reviewed Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. LPA observed the First Aid Kit that has all required items. Resident Records/Incident Reports: LPA reviewed five (5) resident files that included the Face Sheet, Admission Agreements, Physician's Reports, Ambulatory Status, TB Clearance, Preplacement Appraisal, Appraisal/Needs and Services Plan, Safeguards for Property/Valuables, and Personal Rights. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least two (2) relocation sites. Facility maintains documentation of the required emergency drills. Residents with Special Health Needs: Per Administrator, no resident receives hospice care and there are no bedridden residents. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit interview was held and a copy of this report was provided to the Administrator, Gabrielle McDonald.the state’s words, verbatim · CDSS document, May 26, 2026

Allegation investigated: Staff are not assessing residents for a higher level of care. Staff are not checking on residents in a timely manner. Untrained staff providing care to residents.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit regarding the above stated allegations. LPA met with Gabriela McDonald, administrator in training and explained the reason for the visit. Shortly after, Sister Magdalene Grace, RN, Care Coordinator arrived and assisted LPA. The investigation consisted of the following: LPA conducted a tour of the facility's common areas, obtained/reviewed copy of the staff & resident rosters, (2) random Med Tech files (certification, training, and competency assessments), Staff mandatory training logs (Jan 2026-Mar 2026), Incident Reports (Jan 2026-Mar 2026), (5) random resident files such as Identification and Emergency information, Physician’s report, Physician's orders, Preadmission appraisals/reappraisals, Care plans, Medication Administration Record (MAR) (Jan 2026-Mar 2026). LPA interviewed Staff #1 (S1) – Staff #4 (S4) and Resident #1 (R1) – Resident #5 (R5). *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: Allegation: “Staff are not assessing residents for a higher level of care”, it is alleged that the facility is retaining residents who need higher-level of care, as many residents show signs of dementia and Alzheimer’s disease. All (4) staff interviewed denied the allegation and stated that they do not have residents with dementia or Alzheimer’s disease. Staff indicated that some of the residents may have mild cognitive impairment but can still perform their daily activities. Staff stated that they assess residents regularly for any changes in their condition. S1 stated that they know not to retain residents with dementia or Alzheimer’s disease as they require a higher level of care that the facility is licensed to provide. All (5) residents interviewed denied the allegation and stated that they are quite independent and can manage their daily tasks. Residents stated they experience memory lapses at times or have occasional forgetfulness (like misplacing items) but are aware that those are part of aging. During interviews, LPA observed that residents appeared alert and communicative. A review of (5) random physician’s reports revealed that none of the patients have been diagnosed with dementia or Alzheimer's disease. In addition, the incident reports revealed a low incident rate of falls, injuries, or changes in conditions, as well as no reports of re-occurring issues. Therefore, there is insufficient evidence to corroborate the allegation. Allegation: “Staff are not checking on residents in a timely manner.” It is alleged that the facility often keeps residents with cognitive impairment alone in their rooms without proper supervision or care and that some residents rarely come out of their rooms. All (4) staff interviewed denied the allegation, stating they provide necessary care and supervision, have adequate staffing, including night and on-call staff and follow residents' care plans. Staff also stated they completed the necessary training, including shadowing. All (5) residents interviewed denied the allegation, praising the staff for their care and timely responses to calls using pendants or call lights. Residents stated they can handle their everyday tasks, need minimal assistance and are free to stay or leave their rooms whenever they want. During the visit, LPA pressed the resident’s call light in Room C4's bathroom to check response times, and it took staff 01:03.58 minutes to respond to the call. LPA observed the residents to be clean and interact well with staff and other residents. Therefore, there is insufficient evidence to corroborate the allegation. Allegation: “Untrained staff providing care to residents.” It is alleged that facility regularly brings in caregivers from third-party staffing apps to fill shifts, with staff that are not properly trained and may not hold appropriate qualifications to care for residents with significant cognitive impairment. All (4) staff interviewed denied the allegation, stating that before staff are allowed to work, they must complete the required training to provide proper care to residents. Staff interviewed stated that nurse registry has been contracted to cover for staff who are out, and S1 verifies their qualifications and training. S1 indicated they also have a third party insurance company that set up a care team that includes doctors and nurse practitioners. The team visits residents who have enrolled in the program once a month, or as necessary and offers labs and x-rays to residents who choose not to leave the community. All (5) residents interviewed stated the staff have never handled them improperly or have given them the wrong medications and assist them with their personal hygiene. Staff training was reviewed and showed that care giving staff, including med techs, have the required certification and training. During the visit, LPA did not observe signs of improper care such as rough handling or poor hygiene of the residents. Incident reports were also reviewed and did not show recurrent falls, injuries or medication errors. Therefore, there is insufficient evidence to corroborate the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was held and a copy of this report was provided to Gabrielle McDonald, Administrator in training and Sister Magdalene Grace, RN, Care Coordinator.the state’s words, verbatim · CDSS document, Apr 16, 2026 · control 28-AS-20260407140424

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Daniel Konishi and Elena Mallett conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPAs met with and Nathan Nemeth and explained the purpose of the visit. There are currently (18) elderly residents 60 years and older residing in the facility. Facility is licensed to care for elderly residents age range 60 and over, 28 ambulatory, of which 28 may be non-ambulatory, hospice waiver for 7. Shortly after, LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has s Infection Control Plan in file. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Hospice Waiver for 7 is approved. A fire clearance is in place. Fire Drill was last conducted on 4/14/2025. Disaster Drill was last conducted on 4/14/2025. Based on record review, Valid Liability Insurance was not file. Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor: reception area, living room with covered fireplace, dining area, (11) resident bedrooms, administration office, break room, nurses/medication room, kitchen, storage room, laundry room, conference room and outdoor seating/patio areas. Second floor: (11) resident bedrooms, living room with covered fireplace, Food storage room, Electrical room, Break room, Housekeeping room, elevator/telephone/data room, and laundry room. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Physical Plant/Environment Safety: Bathroom has non-skid materials and contained hygiene supplies including liquid soap, paper towel and toilet paper. There is a fireplace in the living room in each floor that is secured and fully covered. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to residents. There are (9) fire extinguishers observed in the entire facility that were fully charged and serviced on 05/09/2024. LPAs tested hot water temperature in nine (9) random resident rooms and measured within the required 105 - 120 degrees Fahrenheit. Water temperature readings are as follows: Room C1 - 113.1 deg F Room C3 - 113.1 deg F Room C7 - 112.8 deg F Room C10 - 114.6 deg F Room C20 – 111.3 deg F Room C22 – 111.3 deg F Room C24 – 111.3 deg F Room C26 - 112.2 deg F Room C29 - 115.3 deg F Staffing: Facility has a sufficient staffing to provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records/Staff Training: LPAs reviewed the Administrator and four (4) staff files and confirmed health screenings and fingerprint clearances. LPAs reviewed employee rights, staff training, health clearance, vaccinations and 1st Aid/CPR training. However, based on record review, Staff #2 (S2’s) file did not have a valid 1st Aid training in file. Nathan Nemeth’s Administrator certificate is valid and will expire on 12/09/2026. Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Per staff, facility provides internet services to all residents and have access to the facility phone. LPAs interviewed four (4) residents. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Activities calendar is up to date and posted near the dining area. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be using disposable gloves while working. Incidental Medical and Dental: Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Resident Records/Incident Reports: Resident files are maintained at the facility. A total of three (3) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical consent, Medication records. RCFE complaint poster and Personal rights were observed posted in the 1st floor. Disaster Preparedness: Emergency and Disaster Plan LIC 610E updated on 02/25/2025 and is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Currently, one (1) resident receives hospice care and zero (0) bedridden residents. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the Administrator, Nathan Nemeth.the state’s words, verbatim · CDSS document, Jul 3, 2025

Allegation investigated: Staff is refusing to accept resident back after hospital stay

Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial unannounced complaint visit to investigate the allegation listed above. LPA met with Nathan Nemethe, administrator for the facility, and explained the purpose of the visit. The investigation consisted of the following: LPA interviewed Staff #1 - 2 (S1 - S2), and also obtainted the Admissions Record, Admission's Agreement, most recent Physician's Report, most recent Appraisal, and also hospital records dated 3/27/2025 for Resident #1 (R1). LPA attempted to interview R1, however they are currently hospitalized at the time of the visit. The investigation revealed the following: In regards to the allegation that "Staff is refusing to accept resident back after hospital stay," it is alleged that that following R1's hospitalization on 3/1/2025, they have not been accepted back into the facility due to the level of care R1 requires. Unsubstantiated During interviews with the staff, none of them corroborated the allegation. One of the staff interviewed stated that since R1's hospitalization, the physician that has been attending to R1 at the hospital has determined that the resident is currently bedridden and requires total assistance with their Activities of Daily Living (ADLs), and the facility is not licensed to care for any bedridden residents. Another staff interviewed confirmed that R1 does require a higher level of care, and that the physician attending to R1 has stated that he requires care at a skilled nursing facility (SNF). The staff stated that if R1 recovers after rehabilitation at the SNF then they would be able to return to the facility. During record review, LPA confirmed that the facility does not have an approved fire clearance for any bedridden rooms. In reviewing the most recent physician's report for R1 dated 3/28/2025, it documents that R1 is ambulatory status is now "bedridden." Review of the hospital records for R1 dated 3/27/2025 also document that they require maximum assistance with their bed mobility, all transfers, and that their anticipated discharge disposition is a skilled nursing facility. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 1, 2025 · control 28-AS-20250327151212

Allegation investigated: Staff caused injury to a resident.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit to investigate the above mentioned allegation. LPA met with Nathan Nemeth, Administrative Assistant and explained the purpose of the visit. Shortly after, Sister Cecilia Marie, OCD, Care Assistant arrived and assisted LPA. The investigation consisted of the following: LPA toured the facility's common areas and obtained/reviewed a copy of the Staff/Resident rosters and interviewed Staff #1 (S1)-Staff #2 (S2). In regards to the allegation: "Staff caused injury to a resident." LPA interviewed Staff #1 (S1)-Staff #2 (S2) who stated that Resident/Alleged Victim is not a resident of the facility and have never been a resident of the facility. S1-S2 stated that some staff are aware of the allegation and the Resident/Alleged Victim resides in the other (RCFE) facility adjacent to this licensed facility. LPA reviewed the Resident roster (dated 09/09/2024) and resident is not listed on the roster. Therefore, the complaint was written for the wrong facility. This agency has investigated the complaint alleging "Staff caused injury to a resident". Based on the information gathered during this visit, and the staff interviews, the allegation is deemed UNFOUNDED. A finding of UNFOUNDED means that the allegation is either false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted with Nathan Nemeth, Administrative Assistant and a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Sep 17, 2024 · control 28-AS-20240913133346

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPAs met with and Sister Magdalene Grace, Care Coordinator and explained the purpose of the visit. There are currently (17) elderly residents 60 years and older residing in the facility. Facility is licensed to care for elderly residents age range 60 and over, 28 ambulatory, of which 28 may be non ambulatory, hospice waiver for 7. Shortly after, LPAs met with Miguel Angel Gonzalez, Maintenance Technician/Supervisor who assisted us with the Physical Plant tour. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed.  There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Hospice Waiver for 7 is approved. A fire clearance is in place. Fire Drill was last conducted on 4/29/2024. Liability Insurance is in place and expires 06/15/2024. Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor: reception area, living room with covered fireplace, dining area, (10) resident bedrooms, administration office, break room, nurses/medication room, kitchen, storage room, laundry room, conference room and outdoor seating/patio areas. Second floor: (11) resident bedrooms, living room with covered fireplace, Food storage room, Electrical room, Break room, Housekeeping room, elevator/telephone/data room, and laundry room. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathroom has non-skid materials and contained hygiene supplies including liquid soap, paper towel and toilet paper. There is a fire place in the living room in each floor that is secured and fully covered. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to residents. There are (9) fire extinguishers observed in the entire facility that were fully charged and serviced on 05/09/2024. LPAs tested hot water temperature in seven (7) random resident rooms and measured within the required 105 - 120 degrees Fahrenheit. Water temperature readings are as follows: Room C1 - 114.6 deg F Room C2 - 114.2 deg F Room C6 - 115.8 deg F Room C7 - 115.3 deg F Room C9 - 114.0 deg F Room C21 - 115.1 deg F Room C28 - 115.1 deg F *****CONTINUED ON LIC809-C**** Staffing: A total of twenty one (21) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. LPAs interviewed (4) staff. Personnel Records/Staff Training: LPAs reviewed four (4) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Kathryn Klein/Sister Marie Estelle's Administrator certificate is valid and will expire on 12/23/2024. Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Per staff, facility provides internet services to all residents and have access to the facility phone. LPAs interviewed (4) residents. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Activities calendar is up to date and posted near the dining area. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be using disposable gloves while working. Incidental Medical and Dental: Four (4) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Resident Records/Incident Reports: Resident files are maintained at the facility. A total of three (3) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical consent, Medication records. RCFE complaint poster and Personal rights were observed posted in the 1st floor. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Currently, one (1) resident receives hospice care and zero (0) bedridden residents. No deficiencies cited. An exit interview was conducted, and a copy of this report was provided to Nathan Nemeth, Administrative Assistant.the state’s words, verbatim · CDSS document, May 31, 2024