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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200980
Report Date: 11/17/2023
Date Signed: 11/17/2023 06:24:13 PM

Document Has Been Signed on 11/17/2023 06:24 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:
11/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Doreen Khan, AdministratorTIME COMPLETED:
06:40 PM
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On 11/17/2023 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with staff, Shirlene Devi and explained the reason for the visit. Administrator, Doreen Khan arrived 20 minutes later. The facility’s fire clearance was approved for 4 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and purchased on 5/3/2023. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 105 degrees F in the hallway bathroom. There were adequate lights in each room. First Aid kit is complete. No bodies of water observed. Indoor and outdoor passageways were free of obstruction.

LPA reviewed 4 client and 3 staff files starting at 1:59PM. LPA interviewed 2 clients and 1 staff starting at 3:00PM. LPA reviewed a sample of client's medications starting at 4:30PM.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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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