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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200847
Report Date: 02/09/2023
Date Signed: 02/09/2023 10:38:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2023 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20230203094936
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:
02/09/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Lester Calma, CaregiverTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Licensee did not ensure a refund was issued to residents repsonsible party
INVESTIGATION FINDINGS:
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On 2/9/2023 at 9:50AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a complaint investigation in regard to the allegation above. LPA met with caregiver, Lester Calma and informed him the reason for visit. LPA spoke with administrator (ADM), Merdith Castro over the phone and was informed that she wasn't able to be at the facility and caregiver can sign the report.

Based on record reviews and interview, resident (R1) was admitted at the facility on 10/18/2018 and pass away on 06/24/22. ADM confirmed R1's authorized representative (POA) made an advance payment for four months from July 2022 through October 2022 for R1's care. On 6/24/22, R1 passed away at the facility and her personal belongings were removed on 6/29/22. S1 admitted that S1 is aware of the situation and is having the accountant working on the refund.

Report contiunes on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20230203094936
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 019200847
VISIT DATE: 02/09/2023
NARRATIVE
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Monthly service cost $ 6000 plus additional level of care $ 300 total $6300 x 4 = 25,200 subtract ($1260) the 5% discount from the facility total refund is $23,940.

LPA discussed refund check for the reminder total of $23,940 based on the advance 4 months payments total refund due to POA for the 4 months in advance from July to October 2022.



Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation was found to be SUBSTANTIATED.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230203094936
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 019200847
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2023
Section Cited
HSC
1569.652(c)
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1569.652
Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds
(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.
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LPA discussed with Administrator upon the refunding of the advance payment of 4 months from July 2022 to October 2022 by the POC dates.
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This requirement was not met as evidenced by not refunding of R1’s 4 months advance pay from July 2022 to October 2022. On 6/24/22, R1 passed away at the facility and her personal belongings were removed on 6/29/22 which was in violation of health and safety code.
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Administrator agree to refund the amount of $23,940 to R1 POA and send a confirmation to LPA by POC date.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3