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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201220
Report Date: 04/08/2024
Date Signed: 04/08/2024 02:06:11 PM


Document Has Been Signed on 04/08/2024 02:06 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
OAKLAND ASC, 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:
04/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Caregiver, Isagani SilvestreTIME COMPLETED:
02:16 PM
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On 04/08/2024 at 1:50 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of CCLD receiving notification of a Resident being relocated to facility due to a fire at another facility. LPA met with Caregiver, Isagani Silvestre and explained the purpose of the visit. Administrator was unavailable.

LPAs toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 105.3 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked. Smoke detectors are interconnected with the sprinkler system. A comfortable temperature was maintained at 70 degrees F. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 06/06/2023. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

LPA spoke with R1 and R2 to see how they are adjusting to the facility. R1 and R2 have dementia and were unable to give coherent answers. Administrator has residents files and medications at the facility.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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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