<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200980
Report Date: 09/25/2024
Date Signed: 09/25/2024 12:01:06 PM

Document Has Been Signed on 09/25/2024 12:01 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/
DIRECTOR:
KHAN, DOREENFACILITY TYPE:
735
ADDRESS:300 SHEPHERD AVETELEPHONE:
(510) 303-0553
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 4DATE:
09/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Doreen Khan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/25/2024 at 11:00AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Case Management Inspection in regard to a special incident report received. LPA met with staff, Shirlene Devi and informed her the reason for the visit. Administrator, Doreen Khan arrived 20 minutes later.

Special incident report dated 9/12/2024 states that C1 refused medication and later got admitted to the hospital due to C1 refused of eating/ drinking. C1 is currently still in the hospital. C1's case manager, doctor and psychiatrist were notified.

When arrived LPA observed that there is no clients at the facility, due to day program, in the community, and one in the hospital. During visit, LPA interviewed staffs. LPA reviewed C1's file and observed that C1’s refused to take C1 medication and have a behavior of seeking for attention and likes to call law enforcement and like to go to the hospital mostly is for transportation/ minor discomfort (have medication for the minor pain). Staff stated that a meeting was held with RCEB, client, administrator regarding C1's missed medication and other topics. C1's doctor and psychiatrist has been notified of the missed medication and is now in the hospital for vital observation. Prior to the hospitalization C1’s saw C1 psychiatrist last August 21, 2024, PCP visit was on 9/18/24 together with C1’s follow up appointment for 9/12/24 ER visit. Administrator will work with C1’s team to work out a plan in term of C1’s care needs.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1