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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200847
Report Date: 11/18/2022
Date Signed: 11/18/2022 02:23:17 PM

Document Has Been Signed on 11/18/2022 02:23 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 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:
11/18/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Lester Calma, CaregiverTIME COMPLETED:
02:35 PM
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On 11/18/2022 at 1:40PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a POC (proof of correction) inspection. LPAs met with caregiver, Lester Calma informed him the reason for the visit.

The following deficiency was cleared by visit:
- 87205(a); As of 11/1/2022, RO (Regional Office) cease request for audit documents.
- 87156(a); LPAs observed licensee paid facility fees on 11/1/2022.


Civil penalties of $1200 is assessed for the period of 10/21/2022 to 11/1/2022 for failure to correct for deficiency 87205(a). Civil penalties of $1200 is assessed for the period of 10/21/2022 to 11/1/2022 for failure to correct deficiency 87156(a). Total civil penalties in the amount of $2400 is being assessed today.


Exit interview conducted. A copy of this report, civil penalties, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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