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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200695
Report Date: 03/17/2022
Date Signed: 03/17/2022 03:14:51 PM


Document Has Been Signed on 03/17/2022 03:14 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 SHEPHERD VISTAFACILITY NUMBER:
019200695
ADMINISTRATOR:KOO, HASMINFACILITY TYPE:
740
ADDRESS:5472 FOOTHILL BLVDTELEPHONE:
(510) 534-5734
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:22CENSUS: 21DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Hasmin Koo, AdministratorTIME COMPLETED:
03:35 PM
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On 3/17/22 at 2:35 p.m. Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Hasmin Koo and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited t:o front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
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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