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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200847
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:29:16 PM

Document Has Been Signed on 09/21/2022 03:29 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:
09/21/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Ofelia Calderon, CaregiverTIME COMPLETED:
01:20 PM
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On 9/21/2022 at 12:50PM, Licensing Program Analysts (LPAs) G. Luk and M. Malik arrived unannounced to conduct a POC (proof of correction) inspection. LPAs met with caregiver, Ofelia Calderon.


Facility has the following deficiency that was not cleared:
- 87205(a); Both LPA G. Luk and Audit Department have not received documents. POC was due on 9/16/2022 and licensee have not provided the documents.


Civil Penalties in the amount of $500 is assess today for the period of 9/17/2022 to 9/21/2022 for failure to meet POC date for deficiency 87205(a). Facility is subject to ongoing civil penalties until deficiency is corrected.


Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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