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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200847
Report Date: 09/14/2022
Date Signed: 09/14/2022 06:16:56 PM

Document Has Been Signed on 09/14/2022 06:16 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: 5DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Merdith Castro, Licensee
Ofelia Calderon, Caregiver		TIME COMPLETED:
06:30 PM
NARRATIVE
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On 9/14/2022 at 2:20PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with caregiver, Ofelia Calderon. Licensee, Merdith Castro arrived an hour later, but unable to stay to sign the report. Licensee gave authority to caregiver to sign CCLD reports.

Upon entry, staff did not conduct COVID-19 screening for LPA. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor areas. LPA observed cough etiquette, signs & symptoms, and physical distancing are posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms.

During record review, LPA observed visitors log and temperature log for residents. LPA observed facility has a copy of Mitigation Plan on file. LPA observed food supplies and paper supplies are sufficient.

At 1:40PM, LPA observed deck gate is in disrepair, outside water faucet near the front door in disrepair, dried pine needles on deck/backyard, and side yard have furniture and other items that needs to be picked up.

At 2:00PM, LPA observed between bedroom 1 and bedroom 2 there was a door that was installed creating an additional resident bedroom. However, this new resident bedroom is a passageway to bedroom 1. LPA was informed by administrator and licensee that the door was installed early 2022 and no permit was obtained.

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 and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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 8
Document Has Been Signed on 09/14/2022 06:16 PM - It Cannot Be Edited


Created By: Grace Luk On 09/14/2022 at 04:32 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: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having deck gate and outside water faucet in disrepair, dried pine needles on deck/backyard, and side yard has items that needs to be disposed which poses a potential health and safety risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee has agreed to schedule bulky pick up for the side yard items, repair deck gate, clean up dried pine needles on deck/backyard, and repair outside water faucet. Licensee will submit pictures or repair/clean up of pine needles, scheduled date of bulky pick up, and receipt for repairs to CCLD by POC date.
Type B
Section Cited
CCR
87307(a)(2)(C)
Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function....The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a resident's bedroom as a passageway to bedroom 1 which poses a potential personal rights violation to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee has agreed to submit a written plan to extend bedroom 1 to create a share room for R1 and R2. Licensee will submit the written plan to CCLD by POC date.
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: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/14/2022 06:16 PM - It Cannot Be Edited


Created By: Grace Luk On 09/14/2022 at 05:47 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: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Building or New Facilities

(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not having permit for the installation of the door to create a new bedroom between room 1 & 2 which poses a potential health and safety risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee has agreed to submit a written plan to obtain building permits, LIC200, and a new sketch to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022


LIC809 (FAS) - (06/04)
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