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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200847
Report Date: 10/25/2022
Date Signed: 10/25/2022 10:11:53 AM

Substantiated


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, CargiverTIME COMPLETED:
10:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not allow home health to care for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 facility informed the family that they were not allowing the home health agency to enter the facility on multiply occasions.

Continued on 9099-C
Substantiated
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 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2022
Section Cited
CCR
87468.1(b)(8)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities: Deny or restrict medical or nonmedical care … unduly demeans the resident’s dignity or causes avoidable discomfort. This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to review regulation 87468.1 and submit self-certification to CCLD by POC date.
8
9
10
11
12
13
14
Based on LPAs record review Licensee did not comply with the section cited above by not allowing home health agency at the facility which poses a potential health and safety risk for persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
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
26
27
28
29
30
31
32
Continued from 9099

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited.

Exit interview conducted. A copy appeal rights, and 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: 3 of 3