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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200847
Report Date: 02/03/2023
Date Signed: 02/03/2023 12:50:15 PM

Document Has Been Signed on 02/03/2023 12:50 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:
02/03/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Lester Calma, CaregiverTIME COMPLETED:
01:05 PM
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On 2/3/2023 at 11:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a POC (proof of correction) inspection. LPA met with caregiver, Lester Calma informed him the reason for the visit.

The following deficiency was cleared by visit:
- 87405(d); LPA received email from licensee on stating new administrator was hired.
- 87205(a); LPA received a written statement/plan on 1/5/2023.
- 87213; LPA received a written statement/plan on 1/5/2023.
- 87755(b); LPA received a written statement/plan on 1/5/2023.


Civil penalties of $800 is assessed for the period of 12/29/2022 to 1/5/2023 for failure to correct for each deficiencies 87405(d), 87205(a), 87213, and 87755(b). Total civil penalties in the amount of $3200 is being assessed today.


Exit interview conducted. A copy of this report, POC letters, civil penalties, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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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