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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200020
Report Date: 01/31/2024
Date Signed: 01/31/2024 01:42:50 PM

Document Has Been Signed on 01/31/2024 01:42 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GOOD SAMARITAN RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200020
ADMINISTRATOR:FRANKLIN E. BAUTISTAFACILITY TYPE:
735
ADDRESS:275 JACKSON STREETTELEPHONE:
(510) 886-1821
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
01/31/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Franklin E. Bautista, AdministratorTIME COMPLETED:
02:00 PM
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On 1/31/2024 at 12:30PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. LPA met with Administrator, Franklin Bautista and informed him the purpose for visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, dining area, kitchen and outdoor area. Hot water temperatures was measured at 108.1 and 114.2 degrees Fahrenheit. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Client's medications were kept locked in the medication cabinet located in kitchen. Carbon monoxide and smoke detectors were observed. First-aid kit was complete. Fire extinguisher was last purchased on 05/13/2023. There are no accessible bodies of water observed. Indoor and outdoor passageways were free of obstruction.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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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