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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200980
Report Date: 10/01/2024
Date Signed: 10/01/2024 12:55:42 PM

Document Has Been Signed on 10/01/2024 12:55 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:SHEPHERD HOUSEFACILITY NUMBER:
019200980
ADMINISTRATOR/
DIRECTOR:		KHAN, DOREENFACILITY TYPE:
735
ADDRESS:300 SHEPHERD AVETELEPHONE:
(510) 303-0553
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 4DATE:
10/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Doreen Khan, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 10/1/2024 at 12:30PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Case Management Inspection in regard to a special incident report received. LPA met with Administrator, Doreen Khan and explained the purpose of the visit.

Special incident report dated 9/30/2024 states that C1 got discharged from the hospital and is having acute heart failure. Doreen stated that she is in communication with the hospital due to the request that they are making, which is having C1 monitoring C1 glucose. Doreen stated C1 have not received any insulin kit. Doreen is working with C1 after insulin kit arrive to educated C1 upon self-test. Doreen is working closely with C1 PCP, RCEB Case manager/ Supervisor. Doreen and staff is closely monitoring C1 after the hospital discharge. LPA reviewed C1 After Visit Summary indicating that C1 needs to monitor glucose and close diet. Doreen stated that C1 is not being compliance with the diet that was being instructed by the doctor. Doreen already informed C1 CM, PCP, C1 dad, and the nurse and doctor from the hospital.

No deficiencies are being cited on this date.



Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2024
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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