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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201220
Report Date: 03/23/2023
Date Signed: 03/23/2023 11:37:19 AM


Document Has Been Signed on 03/23/2023 11:37 AM - 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:GOOD SHEPHERD OF SAN RAMONFACILITY NUMBER:
079201220
ADMINISTRATOR:CASTRO, ROCHEFACILITY TYPE:
740
ADDRESS:2752 MOHAWK CIRTELEPHONE:
(925) 719-9351
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 6DATE:
03/23/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Isagani Silvestre, Administrator
Roche Castro, Applicant		TIME COMPLETED:
11:45 AM
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On 03/23/23 at 10AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct a Change of Ownership Pre-licensing inspection. LPA met with Administrator and explained the purpose of the visit. The facility currently has 6 residents.

The facility has an approved fire safety clearance for five (5) non-ambulatory and one (1) bedridden resident.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and back yard. The facility has a total of six (6) bedrooms, one (1) being used for an office and three and one-half (2 1/2) bathrooms. There were no bodies of water present during inspection. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with non skid mats and grab bars. Passageways and hallways are free of obstruction. Locked closet available to store medications and toxins. Locked cabinet to store sharps. Hot water temperature is measured at 108.9 degrees Fahrenheit. Fire extinguisher was last serviced on 06/20/22. There is a minimum of 7-day non-perishables and 2-day perishables foods. Carbon monoxide and smoke detectors present. First-Aid kit was observed complete.

No issues were noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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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