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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200695
Report Date: 02/02/2021
Date Signed: 02/02/2021 04:09:19 PM

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 SHEPHERD VISTAFACILITY NUMBER:
019200695
ADMINISTRATOR:KOO, HASMINFACILITY TYPE:
740
ADDRESS:5472 FOOTHILL BLVDTELEPHONE:
(510) 534-5734
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:22CENSUS: 20DATE:
02/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Hasmine Koo, LicenseeTIME COMPLETED:
03:45 PM
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On 2/2/2021 at 3:00 PM, Licensing Program Analyst (LPA) L. Francisco conducted a Health and Safety Case Management televisit via Facetime due to Shelter in Place ordered by the Governor. LPA spoke with Licensee, Hasmine Koo. .

Community Care Licensing obtained information from another Agency that facility is in financial distress. LPA toured facility including but not limited to common areas, kitchen, random residents' room, and courtyard. LPA observed 2 day perishable and 7 day non-perishable food supply Licensee measured hot water and LPA observed hot water is maintained at 110 degrees F. LPA observed lighting to be adequate for the comfort and safety of the residents. LPA observed residents watching TV in the common area while maintaining social distancing. Residents appeared to be well groomed. First aid kit was observed to be complete. Smoke detectors, sprinklers and carbon monoxide were observed.

No deficiencies cited during televisit. Exit interview conducted and a copy of report will be provided via email. LPA will continue to follow-up with Licensee.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2021
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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