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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 02:14:56 PM

Document Has Been Signed on 11/18/2022 02:14 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Lester Calma, CaregiverTIME COMPLETED:
01:40 PM
NARRATIVE
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On 11/18/2022 at 12:50PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a case management visit. LPAs met with caregiver, Lester Calma.

After reviewing audit report, the following deficiencies were observed.

- 87405 Administrator Qualifications and Duties
- 87205 Accountability of Licensee
- 87213 Finances
- 87755 Inspection Authority


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.

LPA will email a copy of the reports and appeal rights to licensee at a later time.

Exit interview conducted. A copy of this report and appeal rights was 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)
Page: 1 of 3
Document Has Been Signed on 11/18/2022 02:14 PM - It Cannot Be Edited


Created By: Grace Luk On 11/18/2022 at 12:59 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: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2022
Section Cited
CCR
87405(d)

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Administrator - Qualifications and Duties. The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...
This requirement is not met as evidence by:
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Licensee has agreed to hire a new administrator and provide new administrator information to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by the unwillingness to provide documents and communicate with CCLD which poses an immediate health and safety risk to the persons in care.
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Type A
11/21/2022
Section Cited
CCR87205(a)

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Accountability of Licensee Governing Body. The licensee ...shall exercise general supervision over the affairs of the licensed facility... This requirement is not met as evidence by:
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Licensee has agreed to provide a written statement addressing future compliance with regulations and accountability of licensee. Licensee will submit written statement to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by the unwillingness to provide documents to audit department 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.
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: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/18/2022 02:14 PM - It Cannot Be Edited


Created By: Grace Luk On 11/18/2022 at 01:27 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: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2022
Section Cited
CCR
87213

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Finances. The licensee shall have a financial plan that conforms to the requirements of Section 87155...shall maintain adequate financial records... This requirement is not met as evidence by:
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Licensee has agreed to provide a written plan to maintain a financial records and made available upon request. Written plan will be submitted to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by the unwillingness to provide documents to audit department which poses an immediate health and safety risk to the persons in care.
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Type A
11/21/2022
Section Cited
CCR87755(b)

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Inspection Authority of the Licensing Agency. The licensee shall ensure...the examination of all records relating to the operation of the facility. This requirement is not met as evidence by:
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Licensee has agreed to provide a written statement of understanding to provide documents upon request in the future. Written statement will be submitted to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by the unwillingness to provide documents to audit department 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: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
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