Good Shepherd Home

Allegation investigated: Facility staff serve residents expired food. Facility staff did not ensure that expired food was discarded.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the allegations listed above. The purpose of the visit was explained to Licensee Fedelito Ruiz. The investigation consisted of: A physical plant tour of the home was conducted. A total of 4 staff were interviewed. Only 1 resident was interviewed. All other resident have limited verbal/cognitive ability and/or are non-verbal. Resident files were reviewed. Copies of resident modified diet physician orders, face sheets, staff roster, and resident roster were obtained. *Note: During physical plant observations, split bed rails and three-quarter length bed rails were observced. A case management report was generated to issue a citation for postural supports. Substantiated Allegation: Facility staff serve residents expired food. It is alleged that on On September 29, 2025, a Regional Center Quality Assurance and Compliance Specialist conducted an unannounced visit and found expired produce [lettuce & strawberries], container lid with mold, and food containers with mold in the kitchen refrigerator. A total of 4 staff were interviewed. All staff acknowledged the allegation. Staff interviews revealed that one week before the facility had a large family celebration, and staff put left over food in the main refrigerator but did not throw out old food that had mold and was wilted beyond safe consumption. Staff stated that they have never served residents any expired food. One resident was interviewed, they stated the food served is good. They did not have any food complaints. During today's visit, 3 refrigerators were observed in the facility. All refrigerators had food that is safe for consumption and labeled. Licensee stated that a plan of action was put in place the day after Regional Center observations, and all inedible food was discarded right away. Based on record review, a Corrective Action Plan was issued on October 28, 2025. LPA obtained picture evidence of expired food. Therefore, there is sufficient evidence to support the allegation. Allegation: Facility staff did not ensure that expired food was discarded. The complaint alleges the 7-day non-perishable food pantry had 15 items that were expired. The expiration date of the 8 canned food and 5 bags of instant potatoes ranged from 11/2024 to 9/28/2025. All staff acknowledged the allegation and stated that expired food items were an oversight, and moving forward they have put in place staff protocols that ensures canned food expiration dates are marked and checked prior to use. The resident that was interviewed had no knowledge of the allegation. LPA observed the food pantry now has two separate storage spaces, one of residents and the other for staff use. No expired food pantry items were observed today. Resident file review indicates 4 residents have physician orders for modified food diets. Based on record review, the Regional Center issued a Corrective Action Plan dated October 28, 2025 and a Semi-Annual Residential Review that states deficiencies were observed during the visit that resulted in substantial inadequacies. Therefore, there is sufficient evidence to support the allegation. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited according to California Code of Regulations, Title 22. See LIC 9099D. An exit interview was conducted with Administrator Fedelito Ruiz. A copy of the report and appeal rights was issued.the state’s words, verbatim · CDSS document, Nov 4, 2025 · control 28-AS-20251029124547

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(28) · Plan of correction due date: Nov 11, 2025

General Food Service Requirements. The following food service requirements shall apply: All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement was not met evidenced by: On 9/29/25, Regional Center specialist observed wilted lettuce, strawberries with mold, and food containers with mold in the kitchen refrigerator. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Licensee stated the expired food was immediately removed and a plan of action was put in place the following day (9/30/25). 1. Administrator agreed to submit proof of staff training. 2. Plan of Action and logs were provided today. Licensee shall inspect all food storage areas and discard all expired cans. Licensee shall submit a written statement, that all expired cans were discarded and will monitor food supply frequently. Submit self-certification by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Nov 11, 2025

General Food Service Requirements. The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. On 9/29/25, Regional Center specialist observed that 7-day non-perishable food pantry had 15 items that were expired. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Licensee shall ensure staff inspect all food storage areas and discard all expired cans. Licensee provided a copy of the plan of action put in place 9/30/25, food supply will be checked weekly and staff will sign a log. 1. Submit proof of staff training.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Galarza conducted a Case Management- Deficiencies visit due to observations made while investigating complaint control #: 28-AS-20251029124547. The purpose of the report was explained to Licensee Fedelito Ruiz. Observations: Resident (R1's) bed had split bed rails. Physician order is in place for half length rail only. Resident (R2's) bed had a three-quarter length bed rails. Physician order is in place for half length rail only. Underneath resident (R3's) bed a three-quarter length bed rail was observed. Physician order is in place for half length rail only. Staff were interviewed and pictures were taken. Per Title 22, 87608 (a)(5)(A) Postural Supports. Postural Supports. Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Pursuant to Title 22 California Code of Regulations, a deficiency was cited. Exit interview held with Fedelito Ruiz. A copy of the report and appeal rights was issued.the state’s words, verbatim · CDSS document, Nov 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5)(A) · Plan of correction due date: Nov 11, 2025

Postural Supports. Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Based on observation, resident (R1's) bed had split bed rails, (R2's) bed had a three-quarter length bed rails, and underneath resident (R3's) bed a three-quarter length bed rail was observed. Physician orders are in place for half length rails only. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Staff agreed to remove one of the split bed-rails in R1's bed, remove R2's three-quarter length bed rail and place a half length rail, and obtain a half length bed rail for R3, and remove the three-quarter bed rail underneath the resident's bed. *Note: R1- R3 have written order from a physician indicating the resident’s need. Submit picture evidence that residents (R1-R3's) beds have half length bed rails.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Elena Nueva, direct support staff for the facility, and explained the purpose of the visit. Administrator Fidelito Ruiz arrived shortly thereafter. There are five (5) residents currently living in the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. The facility consists of a kitchen, a dining room, a living room, two (2) staff bedrooms, an attached garage the contains the laundry area for the facility, a front yard that contains a shaded area, four (4) resident bedrooms, two bathrooms of which Restroom #1 had a hot water temperature reading of 107.6 Degrees Fahrenheit, and Restroom #2 which had a hot water temperature reading of 106.2 Degrees Fahrenheit. The facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has a fully charged fire extinguisher kept in the facility. Operational Requirements: · Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, five (5) of whom may be non-ambulatory, one (1) of whom may be bedridden, and a hospice waiver approved for one (1) resident. · Care and supervision to meet the clients’ needs was observed. Staffing: · Twelve (12) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · All Five (5) staff records reviewed have a health screening with a Tuberculosis clearance, and five (5) staff have First Aid/CPR trainings that are active. · The administrator’s certificate expires on 1/29/2027. Resident Rights/Information: · Physician orders were reviewed for five (5) resident files. · Medications were also reviewed for five (5) residents. Resident Records/Incident Reports: · Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Individual Program Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan (LIC610E) was posted in the facility. · The last emergency and disaster drill was conducted on 9/1/2025. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report will be provided.the state’s words, verbatim · CDSS document, Oct 7, 2025

Allegation investigated: Facility is in disrepair. Staff did not ensure medical services were provided. Facility did not meet food service requirements.

Licensing Program Analyst (LPA) Mayra Cota visited the facility to conduct the 10-day complaint investigation regarding the allegations listed above. Upon arrival, LPA met with Fidelito Ruiz, Administrator, and the reason for the visit was explained. The investigation consisted of the following: At the time of visit, LPA Cota, obtained copies of staff and resident rosters, conducted a tour of the physical plant with focus on inspecting resident bedroom #4 and resident bathroom #1, conducted record review for Resident #1-4 (R1-R4) and Staff #1-6 (S1-S6) and interviewed S1-S3. Resident menus were also reviewed, and copies of all relevant documents were obtained including facility's Plan of Operation. LPA attempted to conduct interviews with R1-R3, but was unable to due to residents being non-responsive. R4-R6 were not available for interviews due to being away at day program. Continues on LIC 9099-C Substantiated The investigation revealed the following: Regarding allegation: Facility is in disrepair. Interview with S1 revealed that resident bedroom #4 had a hole in the ceiling. S1 interview also revealed, that one of the walls in bathroom #1 was chipped at the bottom and bathroom vent was dirty. S1 interview further indicated, that the repairs and cleaning were completed prior to today’s visit. During visit, LPA observation indicated repairs had been completed for the hole in the ceiling and chipped wall in the bathroom and the vent in the bathroom was cleaned. Based on interview with S1 and LPA observation, the allegation is corroborated; therefore the allegation is SUBSTANTIATED. Regarding: Staff did not ensure medical services were provided. Interview with S1 revealed, an appointment for routine medical services for R1 had not been scheduled because family had not signed the declination/acceptance form which would grant or deny permission for R1 to attend the routine medical appointment. Record review conducted during visit revealed, medical appointment for R1 had not been scheduled; however, there was no documentation indicating family’s decline for a medical appointment until it was sent by family on 5/28/25 . Further record review conducted by LPA indicated, facility staff received the declination for the routine medical appointment from family last year on 12/5/24; however, the decline form for this year had not been requested from family by licensee until 5/28/25. Interview with S1 further revealed, R2’s file was missing Immunization record but review conducted by LPA at the time of visit indicated, R2’s immunization record was present in the file. Record review also showed no indication of R2 attending a dental appointment around the anniversary of last years appointment which took place on 6/24/24 or confirmation of an upcoming scheduled appointment. Licensee scheduled dental appointment for R2 at the time of visit via phone call to dental facility. Based on interview with S1 and LPA record review, the allegation is corroborated and therefore the allegation is SUBSTANTIATED. Continues on LIC 9099-C The investigation revealed the following: Regarding allegation: Staff does not ensure staff are adequately trained. Record review indicated that S1-S6 have the required job training received during initial hire and through continued education for various topics, including but not limited to Reporting and Documentation, Abuse and Neglect Reporting and Dementia Training. Records indicate staff have the initial (40) hours of training provided during orientation and are required by licensee to continue with training throughout the year. Record review further indicated, S1-S6 have certification through continued education for care and supervision for residents in their care. Record review does not corroborate the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Fidelito Ruiz, Administrator, and a copy of this report was provided during visit. Regarding allegation: Facility did not meet food service requirements. Record review and observation conducted by LPA revealed, facility's current menu plan for residents does not offer a variety of foods to meet personal preferences, special dietary needs, food habits and cultural background. Interview with S1 indicated, alternate menu had not been updated nor posted. Based on interview with S1 and LPA record review and observation, the allegation is corroborated and therefore the allegations is SUBSTANTIATED. Based on LPA’s observations, interviews and record review, the preponderance of evidence standard has been met; therefore, the allegations noted above are found to be SUBSTANTIATED. Deficiencies were observed and cited per California Code of Regulation Title 22 Division 6. Refer to LIC 9099-D. Exit interview held with Fidelito Ruiz, Administrator and copy of report and Appeal Rights provided during visit.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 28-AS-20250701150003

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 8, 2025

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on interview and observation, resident bedroom #4 had a hole in the ceiling, one of the walls in bathroom #1 was chipped at the bottom and bathroom vent was dirty which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Licensee completed repairs prior to today's visit by covering/reparing the hole in bedroom #4, reparing the chipped wall in bathroom #1 and cleaning the vent in bathroom #1.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(13) · Plan of correction due date: Jul 8, 2025

87506(b)(13) Resident Records (b) Each resident’s record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. This requirement is not met as evidence by: Based on interview and record review, licensee did not ensure that residents had the proper declination of routine medical appoinment in place and scheduled resident dental appoinment accordingly which poses a potential risk for the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Corrections made during time of visit. Licensee provided LPA with declination for medical services for resident and scheduled dental appoinment via phone call for resident for 8/1/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(5) · Plan of correction due date: Jul 22, 2025

87555 General FoodService Requirements (b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. This requirement is not met as evidence by: Based on record review, current menu plan for residents does not offer a variety of foods to meet personal preferences, special dietary needs, food habits and cultural background which poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: Licensee will create a menu plan with alternative food choices to meet the needs of resident's food habits, preferences and cultural background. Licensee will include a variety of foof items for residents in care by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent unannounced Required 1-year annual continuation visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Fedelito Ruiz, administrator for the facility, and explained the purpose of the visit. There are six residents residing within the home. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control practices were observed. · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, six (6) of which may be non-ambulatory, five (5) of which may be bedridden, and a hospice waiver approved for one (1) resident. The facility consists of a kitchen and dining room, a living room, an office area, three (3) restrooms, six (6) bedrooms, and a backyard area that contains a shaded area. The facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has two (2) fully charged fire extinguishers in the facility. · Water temperature readings for one of the bathrooms in the home did not fall within the required range of 105 - 120 degrees Fahrenheit. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, six (6) of which may be non-ambulatory, five (5) of which may be bedridden, and a hospice waiver approved for one (1) resident. · Care and supervision to meet the clients’ needs was observed. Staffing: · Six (6) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · All staff records reviewed have health a health screening with a Tuberculosis clearance, and all staff have First Aid/CPR trainings that are active. · The administrator’s certificate expires on 1/29/2025. Resident Rights/Information: · Physician orders were reviewed for five (5) resident files. · Medications were also reviewed for five (5) residents. Resident Records/Incident Reports: · Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan was publicly posted and found within the facility. · The last emergency and disaster drill was conducted on 9/2/2024. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs: · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 4, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-Year visit at the facility. LPA was greeted by Elena Baydel, caregiver for the facility, and explained the purpose of the visit. There are currently 6 residents who are currently living in the facility. During visit, LPA conducted a tour of the facility. There are four (4) resident rooms located within the facility, a kitchen, a dining room, a staff bedroom, a staff bathroom, client bathroom, two (2) sheds outdoors that contain miscellaneous supplies, and an attached garage the contains the facility's washer and dryer machines. The facility was observed to be clean and in good repair. Due to time constraints, the annual inspection will need to be completed at a later time. Exit interview held and a copy of this report was provided to Elena Baydel.the state’s words, verbatim · CDSS document, Sep 27, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Fedelito Riuz. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. Infection Control Plan not observed Operational Requirements: A current Plan of Operation with Dementia Care Plan on file. Facility is vendorized through East Los Angeles Regional Center A fire clearance for 6 residents of which (6) may be non ambulatory; (5) may be bedridden. Hospice care waiver approved for one (1) residents. Physical Plant/Environment Safety: Facility is a one story family home with six (6) bedrooms, three (3) bathrooms, living room, kitchen, central air and heating, dining area, gated fire, laundry room, multiple shaded areas located in the front-yard, and an attached garage for storage. The residence is equipped with central air and heating. Fire alarms and sprinkler system operational and inspected up to date. 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. Cleaning supplies and toxic substances are inaccessible. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Staffing: A total of 5 staff members provide supervision to the residents. Sufficient staff observed during visit Continued on LIC 809-C Personnel Records/Staff Training: Administrator on file is current. Staff have criminal background clearance and training. Three (3) staff files were reviewed. Required training observed Resident Records/Incident Reports: A total of six (6) resident files were reviewed. Required postings observed Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Activities supply observed Food Service: Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for clients to use and to store their meals Incident Medical and Dental: Emergency transportation available First Aid Kid observed (6) of (6) Resident medications reviewed Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Residents with Special Health Needs: Needs and Services Plan and Appraisals are on file. There are no special health needs current being provided Inspection Tool was completed. Per Title 22 Regulations, a deficiency is being cited (See LIC 809-D). Exit interview conducted and a copy of this report and appeal rights were provided and discussed.the state’s words, verbatim · CDSS document, Oct 20, 2023