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Inspection visit

Complaint

GOOD SHEPHERD HOMELicense 1976068362 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

Allegation: Facility staff serve residents expired food. It is alleged t hat 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.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • Immediate disposal of contaminated food

    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.

  • 87555(a)Type B

    Diet quality and preparation in safe healthful manner

    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.

  • 87608(a)(5)(A)Type B

    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.

FAQ · About this visit

Common questions about this visit

What happened during the November 4, 2025 inspection of GOOD SHEPHERD HOME?

This was a complaint inspection of GOOD SHEPHERD HOME on November 4, 2025. 2 citations were issued: 2 Type B.

Were any citations issued to GOOD SHEPHERD HOME on November 4, 2025?

Yes, 2 citations were issued (0 Type A, 2 Type B). The first citation was for: "General Food Service Requirements. The following food service requirements shall apply: All food shall be protected agai..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

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