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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200847
Report Date: 10/25/2022
Date Signed: 10/25/2022 10:03:19 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2020 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20200514105042
FACILITY NAME:GOOD SHEPHERD OF DUBLIN, THEFACILITY NUMBER:
019200847
ADMINISTRATOR:CASTRO, MERDITHFACILITY TYPE:
740
ADDRESS:8206 RHODA AVETELEPHONE:
(925) 895-2569
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:6CENSUS: 6DATE:
10/25/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Ofelia Calderon, CaregiverTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility improperly raised resident’s rates
Illegal eviction
INVESTIGATION FINDINGS:
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On 10/25/2022 starting at 09:20 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct complaint investigation for the above allegation. LPA met with caregiver, Ofelia Calderon and explained the purpose of the visit. Licensee Merideth Castro was called and she designated Ofelia to sign off on the report.

During the course of investigation, LPA obtained information, collected documents, and interviewed staff. Documented communication between the resident’s family and the facility show that the facility did initiate eviction of the resident but, later rescinded the eviction and the resident stated at the facility until her death in 2021. Interview with staff stated the only increase that was done was to when resident went on hospice in November of 2020.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20200514105042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOOD SHEPHERD OF DUBLIN, THE
FACILITY NUMBER: 019200847
VISIT DATE: 10/25/2022
NARRATIVE
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Continued from 9099


Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2