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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200980
Report Date: 03/15/2022
Date Signed: 03/15/2022 06:27:00 PM

Document Has Been Signed on 03/15/2022 06:27 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:KHAN, DOREENFACILITY TYPE:
735
ADDRESS:300 SHEPHERD AVETELEPHONE:
(510) 303-0553
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 4DATE:
03/15/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Doreen Khan/Licensee-AdministratorTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced health safety inspection as a result of the Department receiving priority 2 complaint (AS-202203141129379). LPA met with Brittiany Recania-Shields, staff, and Doreen Khan, licensee-administrator.

LPA toured facility including but not limited to the bedrooms, bathrooms, living room, kitchen, and outdoor area. Food supplies of 7-day of non-perishable and 2-day of perishables were adequate. Resident's medications were centrally stored in a locked cabinet. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. One of the residents was at the facility and taking nap when LPA arrived.

No deficiencies are being cited during this visit.

Exit interview conducted with Doreen over the phone in the presence of Brittiany. Copy of this report provided at the conclusion of interview.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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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