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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200020
Report Date: 01/14/2025
Date Signed: 01/14/2025 01:07:29 PM

Document Has Been Signed on 01/14/2025 01:07 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:
01/14/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Arturo Ticman, Care StaffTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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On 1/14/2025, Licensing Program Analyst (LPA) Kelly Nguyen conducted an unannounced case management regarding an incident report that was submitted to CCLD on 1/9/25 regrading a client got admitted to ICU due to high carbon dioxide level. LPA met with care staff Arturo Ticman 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 Arturo to sign the report.

S1 stated C1 have a condition of bowel moment, and it was due to C1 health condition that cause C1 to develop new system which cause C1 abdomen can’t release/ obtained carbon dioxide. S1 clarified and confirmed that this have nothing to do with the environment. This is a new condition that C1 develop due to C1 health condition. We checked everything to rule out any condition that C1 have, but after that S1 called the 911 to get C1 taken to get evaluated. According to S1 C1 Is doing well, but still remind in ICU for a couple more days. S1 will update C1 needs and service plan when S1 gets an update on C1 health condition.

Facility will submit an updated care plan after C1 discharge from the hospital.

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: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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