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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200980
Report Date: 09/25/2024
Date Signed: 09/25/2024 12:26:51 PM

Document Has Been Signed on 09/25/2024 12:26 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:
12:10 PM
MET WITH:Doreen Khan, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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On 9/25/2024 at 12:10PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Case Management Inspection in regard to a special incident report received. LPA met administrator, Dorren Khan and explained the purpose of the visit.

Special incident report dated 9/24/2024 states that C1 got caught walking out of Walmart, with a pair of shoes and is being charge. C1 currently in the community. C1's case manager were notified. Administrator stated that this is C1 first time incident. There is a court date that is set on 11/10/24. C1’s is schedule to have a quarterly review on 10/24/24 and this new behavior will be discussed during the meeting.

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)
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