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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200020
Report Date: 05/22/2024
Date Signed: 05/22/2024 03:15:39 PM

Document Has Been Signed on 05/22/2024 03:15 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GOOD SAMARITAN RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200020
ADMINISTRATOR/
DIRECTOR:		FRANKLIN E. BAUTISTAFACILITY TYPE:
735
ADDRESS:275 JACKSON STREETTELEPHONE:
(510) 886-1821
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
05/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Ellen Jovero, Staff TIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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On 5/20/2024, Licensing Program Analyst (LPA) Kelly Nguyen conducted an unannounced case management regarding an incident report (sexual abuse) received by CCL and met with staff Ellen Jovero. LPA informed staff and Administrator, Frank (via telephone) that the case management is being conducted. Frank was unable to be here and gave verbal permission to Ellen to sign the report.

LPA obtained and reviewed physician's report for Client 1 (C1). LPA interview S1, S2, and S3 regarding the unusual incident report. Physician's Reports for C1 indicate that they are ambulatory and cannot leave the facility unassisted. C1 ended up in the hospital by the ambulance due to behavior. After being evaluated by the hospital C1 was discharge back to the facility by non-emergency ambulance. C1 refused to get off gurney and Hayward Police got involved. C1 was brought to St. Rose Hospital. LPA interviewed C1, C1 was uncleared of the story or time line when incident occurred. After the incident S3 stated that C1 is continuing to be supervised by staff 24/7.

There is no deficiency noted on this day.

Copy of this report provided to Administrator via e-mail.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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