<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200695
Report Date: 06/13/2022
Date Signed: 06/13/2022 02:18:16 PM


Document Has Been Signed on 06/13/2022 02:18 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: 18DATE:
06/13/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Hasmin Koo, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 6/13/22 at 1:45 p.m., Licensing Program Analyst (LPA) G. Clark arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. LPA met with Administrator, Hasmin Koo.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 115 degrees F in the kitchen sink. A 7-day of non-perishable and 2-day of perishable food supplies were observed. Resident's medications were kept locked in a kitchen cabinet. Smoke and Carbon monoxide detectors observed. Fire extinguisher was last serviced on 2/7/22. First-aid kit was complete. There are no accessible bodies of water observed.

No deficiencies noted. Exit interview conducted. A copy of this report and was provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1