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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200980
Report Date: 02/10/2023
Date Signed: 02/10/2023 02:41:44 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
11/19/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20211119084342
FACILITY NAME:SHEPHERD HOUSEFACILITY NUMBER:
019200980
ADMINISTRATOR:KHAN, DOREENFACILITY TYPE:
735
ADDRESS:300 SHEPHERD AVETELEPHONE:
(510) 303-0553
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:4CENSUS: 4DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Doreen Khan, AdministratorTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Staff do not provide a safe environment for resident while in care.
Staff do not seek medical attention for resident when needed.
INVESTIGATION FINDINGS:
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On 2/10/2023 starting at 1:35 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegations. LPA met with Administrator, Doreen Khan and explained the purpose of the visit.

During the course of the investigation, LPA obtained information, reviewed records, collected documents, and interviewed 2 staff, 1 client, and attempted to interview 2 clients. It was alleged staff do not provide a safe environment for resident while in care. Based on information obtained by complainant, facility is allowing client to leave facility and visit individual (AA). LPA reviewed client's physician's report and observed C1 is able to leave the facility unassisted.

REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20211119084342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SHEPHERD HOUSE
FACILITY NUMBER: 019200980
VISIT DATE: 02/10/2023
NARRATIVE
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It was alleged staff do not seek medical attention for resident when needed. Based on information obtained, C1 has self inflicting behavior (SIB) and facility did not seek medical attention. However, LPA reviewed records and observed no incident reports of SIB. LPA discovered during an interview with S1 that C1 has not had any issues of SIB since C1 was admitted to the facility.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to Administrator.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3