019200847-4-12-2024-15-AS-KHOS-D9FKR3-20240925080716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200847
Report Date: 04/12/2024
Date Signed: 04/12/2024 02:01:15 PM

Unsubstantiated

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
07/14/2023 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20230714150033

FACILITY NAME:	GOOD SHEPHERD OF DUBLIN, THE		FACILITY NUMBER:	019200847
ADMINISTRATOR:	CASTRO, MERDITH		FACILITY TYPE:	740
ADDRESS:	8206 RHODA AVE		TELEPHONE:	(925) 895-2569
CITY:	DUBLIN	STATE: CA	ZIP CODE:	94568
CAPACITY:	6	CENSUS: 5	DATE:	04/12/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Merdith Castro, Administrator		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Facility staff are not showering resident
Facility staff are not trained in the operation of the Hoyer lift
Resident left in bed 24/7

INVESTIGATION FINDINGS:

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On 4/12/2024 at 1:00 PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to deliver findings regarding the allegation above. LPA met with Administrator, Merdith Castro.

During the course of investigation, LPA K. Nguyen interviewed R1, and staffs. R1 stated that the facility gives R1 sponge bath daily. R1 stated that R1 is being taking care of very well at the facility. R1 started that I am the person that doesn’t like to go out of bed. The staff encourage me, but I choose not, and do not want to get out of my bed. LPA reviewed 3 staff training record. 3 out of 3 staff are certify on how to operate the Hoyer lift.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted a copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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