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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200847
Report Date: 12/07/2022
Date Signed: 12/07/2022 12:55:30 PM

Document Has Been Signed on 12/07/2022 12:55 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:
12/07/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Ofelia Calderon, CaregiverTIME COMPLETED:
01:10 PM
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On 12/7/2022 at 12:05PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a POC (proof of correction) inspection. LPAs met with caregiver, Ofelia Calderon informed her the reason for the visit. LPAs spoke with licensee, Merdith Castro over the phone and stated that POC will be sent to LPAs later today.

Facility has the following deficiencies that were not cleared and deficiencies were issued on 11/18/2022 from California Code of Regulations, Title 22:
- 87405(d); LPAs have not received new administrator information from licensee.
- 87205(a); LPAs have not received a written statement/plan.
- 87213; LPAs have not received a written statement/plan.
- 87755(b); LPAs have not received a written statement/plan.

POC due date was extended until 11/30/2022 for all four deficiencies.

Civil penalties of $700 is assessed for the period of 12/1/2022 to 12/7/2022 for failure to correct for each deficiencies 87405(d), 87205(a), 87213, and 87755(b). Total civil penalties in the amount of $2800 is being assessed today. Facility is subject to ongoing civil penalties until deficiencies are corrected.

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: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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