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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200847
Report Date: 10/06/2022
Date Signed: 10/06/2022 01:23:06 PM

Document Has Been Signed on 10/06/2022 01:23 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:
10/06/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Lester Calma, CaregiverTIME COMPLETED:
12:15 PM
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On 10/6/2022 at 10:50AM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a POC (proof of correction) inspection. LPAs met with caregiver, Lester Calma informed him the reason for the visit. Licensee, Merdith Castro was unable to be at the facility.

The following deficiency was cleared by visit:
- 87307(a)(2)(C); LPAs observed R2 moved to bedroom 1 and bedroom 1 became a shared room with R1 and R2.

Facility still has the following deficiencies that were not cleared and were issued on 9/14/2022 from California Code of Regulations, Title 22:
- 87205(a); Audit department and Oakland RO have not received any audit documents from licensee.
- 87305(a); Licensee have not provided a written plan to CCLD for obtaining permits on the installation of the door.
- 87303(a); LPAs observed that deck gate was fixed and operable and outside water faucet does not have leakage. However, items along the side yard have not been picked up, dried pine needles on deck/backyard have not been cleaned, and the hole on the outside water faucet was not repaired.

Civil penalties of $1500 is assessed for the period of 9/22/2022 to 10/6/2022 for failure to correct for deficiency 87205(a). Civil penalties of $600 is assessed for the period of 10/1/2022 to 10/6/2022 for failure to correct for each deficiencies 87305(a) and 87303(a). Total civil penalties in the amount of $2700 is being assessed today. Facility is subject to ongoing civil penalties until deficiencies are corrected.

Exit interview conducted. A copy of this report, civil penalties, appeal rights, and POC letter provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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