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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200980
Report Date: 11/03/2023
Date Signed: 11/03/2023 04:30:44 PM

Document Has Been Signed on 11/03/2023 04:30 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:
11/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Doreen Khan, AdministratorTIME COMPLETED:
04:45 PM
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On 11/3/2023 at 2:50PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management Inspection in regards to a special incident report received. LPA met with staff, Georgina Argumendo and informed her the reason for the visit. Administrator, Doreen Khan arrived 20 minutes later.

Special incident report dated 9/24/2023 states that C1 did not return to the facility on the evening of 9/22/2023. C1 called the facility in the morning of 9/23/2023 and apologized for not returning to the facility. C1 returned home on 9/23/2023. C1's doctor and psychiatrist were notified.

During visit, LPA interviewed client and staff. LPA reviewed C1's file and observed that C1 can leave the facility unassisted per LIC602 dated 1/3/2023. Staff stated that a meeting was held with RCEB, client, administrator regarding C1's missed medication and other topics. LPA observed there's a binder for clients to sign in and out when they leave and return to the facility. Staff stated that C1 doesn't always sign the binder when leaving the facility. However, C1 will sometimes let staff know when she leaves the facility. C1's doctor and psychiatrist has been notified of the missed medications and was able to make an appointment in December due to doctor's full schedule. LPA reviewed C1's MAR and observed C1 missed medications only on that day in September.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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