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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200847
Report Date: 04/06/2023
Date Signed: 04/06/2023 10:27:09 AM

Document Has Been Signed on 04/06/2023 10:27 AM - 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:
04/06/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lester Calma, CaregiverTIME COMPLETED:
09:50 AM
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On 4/6/2023 at 9:00 AM, Licensing Program Analysts (LPAs) K. Nguyen and G. Luk arrived unannounced to conduct a POC (proof of correction) inspection. LPAs met with caregiver, Lester Calma. LPAs was unable to speak with the licensee.


Facility has the following deficiency that was not cleared:
- HSC1569.652(c); LPA. K. Nguyen did not receive POC due on 2/24/23 and licensee have not provided the documents.


Civil Penalties in the amount of $1,300 is assess today for the period of 3/25/23 to 4/6/23 for failure to meet POC date for deficiency HSC1569.652(c). Facility is subject to ongoing civil penalties until deficiency is corrected.


Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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