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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200980
Report Date: 07/20/2023
Date Signed: 07/20/2023 03:14:36 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
06/30/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220630103517
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: 3DATE:
07/20/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Doris Khan/AdministratorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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-Staff did not ensure resident (R1) as taken to her appointments.

-Staff did not ensure resident (R1) was seen by a dentist.

-
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation, and close the complaint. LPA was granted entry by Lupita Rodriguez Romero, staff. LPA called and spoke over the phone with Doreen Khan, administrator, and informed the reason. Administrator arrived after several minutes.

During the course of investigation, LPA reviewed residents records and conducted interviews.

Staff (S1) and administrator stated resident (R1) missed her appointments when R1 is out in the community. This was confirmed by LPA with R1 on October 20, 2022.


.....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
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 4
Control Number 15-AS-20220630103517
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: 07/20/2023
NARRATIVE
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Based on information obtained, the 2 allegations are closed as unsubstantiated. An unsubstantiated findings means that although the allegations may have happened or are valid, there are not enough preponderance of evidence to prove that alleged violations occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4