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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200020
Report Date: 11/14/2024
Date Signed: 11/14/2024 01:59:13 PM

Document Has Been Signed on 11/14/2024 01:59 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:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Franklin Bautista, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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On 11/14/2024 at 9:00am Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection and were met by caregiver Elentia Meranda. Franklin (Frank) Bautista, Administrator was informed via telephone about the purpose of visit. The facility is a Level 4i home vendorized by the Regional Center of the East Bay (RCEB). There were clients at the facility upon arrival. Frank arrived after LPA tour the facility around 11am.

Facility has an approved fire clearance for 6 ambulatory residents. LPA inspected the facility inside and out including but not limited to client rooms, bathrooms, kitchen, dining area, laundry room and backyard. Hot water measured at 115 degrees Fahrenheit. Hallways and passageways were free of obstruction. There was sufficient supply of perishable and non-perishable foods. Hygiene and hygiene products were available for the clients. There was supply of warm blankets, towels and sheets observed. There were no bodies of water observed. Chemicals and other toxic products were locked in a shed in the backyard. Knives and other sharp objects were locked in the office. Fire extinguisher appeared full and was purchased on 5/14/24. Last fire drill was conducted on 4/2/2024.

LPA reviewed 6 clients files. 6 out of 6 have current physician report and T. B. on files. LPA reviewed 2 staff records and 3 of 3 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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