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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200020
Report Date: 07/03/2024
Date Signed: 07/03/2024 01:50:50 PM

Document Has Been Signed on 07/03/2024 01:50 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:
07/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Franklin Bautista, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On 7/3/2024, Licensing Program Analyst (LPA) Kelly Nguyen conducted an unannounced case management regarding an incident report of multiples ER visit of a client within the month of June received by CCL on June 26, 2024. LPA informed Administrator (AD), Frank the purpose of the visit.

During the complaint investigation LPA interview AD and found out that C1 had multiple hospitalization within a month, due to C1 doesn’t want to get off the grungy and demanded the EMT to take C1 back to the hospital. LPA interview C1, C1 indicated that C1 want to go back home to C1 mom.

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: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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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