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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200847
Report Date: 10/06/2022
Date Signed: 10/06/2022 01:24:29 PM

Document Has Been Signed on 10/06/2022 01:24 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:
10/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lester Calma, CaregiverTIME COMPLETED:
01:35 PM
NARRATIVE
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On 10/6/2022 at 12:15PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a case management visit. LPAs met with caregiver, Lester Calma. Licensee, Merdith Castro was unable to be at the facility.

While LPAs was at the facility conducting another visit, the following deficiencies were observed.

- LPAs observed facility annual fees were overdue. LPAs informed licensee of overdue facility fees and provided PIN number. Licensee stated that she will pay for the annual fee.

- LPAs observed backyard had large amount of standing water with clogged drain. In the standing water was large amounts of larvas swimming which will become mosquitos. Other life cycles of mosquitos were observed in the standing water in the backyard.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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Document Has Been Signed on 10/06/2022 01:24 PM - It Cannot Be Edited


Created By: Grace Luk On 10/06/2022 at 01:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2022
Section Cited
CCR
87303(a)

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Maintenance and Operation.
The facility shall be clean, safe, sanitary and in good repair at all times...
This requirement is not met as evidence by:
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Licensee has agreed to provide a written plan to address the standing water, various life cycles of mosquitos, and clogged drain. Licensee will submit written plan to CCLD by POC date.
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Based on observeation, licensee did not comply with the section cited above by having standing water in the backyard with various life cycles of mosquitos which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $250 is being assessed for repeat violation.
Type A
10/07/2022
Section Cited
CCR87156(a)

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Licensing Fees.
An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.
This requirement is not met as evidence by:
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Licensee has agreed to pay for annual fees and will submit receipt to CCLD by POC date.
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Based on observeation, licensee did not comply with the section cited above by not paying annual fee which poses an immediate health and safety risk to the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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