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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200020
Report Date: 10/09/2024
Date Signed: 10/09/2024 02:43:55 PM

Document Has Been Signed on 10/09/2024 02:43 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:
10/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Ellen Jovero, Staff TIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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On 10/9/2024, Licensing Program Analyst (LPA) Kelly Nguyen conducted an unannounced case management regarding an incident report that was submitted to CCLD on 10//24 regrading a client choke another client. LPA met with care staff Ellen Jovero and explained the purpose of the visit. Administrator (ADM), Frank was informed and explained the purpose of the visit but was not able to come during the time. ADM gave verbal permission for Ellen to sign the report.

S1 stated C1 asked to use the bathroom, and S1 was waiting outside the bathroom for C1. Once C1 was done with the bathroom C1 got out and walked toward C2 room and S1 tired to redirect C1, but C1 did not listened and forces into C2 room while C2 was sleeping. C2 room is right next to the bathroom, and C2 bed was right next to the door. S1 was not trying to use physical force on C1, but it happened so fast that S2 called the police right away when S1 called out for assistance. Police came right away and tried to redirect C1 but C1 didn’t listen, therefore C1 was handcuff. C1 just got discharge from John George today. C2 was brought to get a check-up the next day. C2 doctor indicated that C2 neck was okay without any mark or any concern.

Facility will submit a plan of prevention to help eliminate similar incident might happen again.

No deficiency issue today.

Exit interview is conducted a copy of this report is provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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