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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201220
Report Date: 02/13/2025
Date Signed: 02/13/2025 02:25:00 PM

Document Has Been Signed on 02/13/2025 02:25 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/
DIRECTOR:		CASTRO, ROCHEFACILITY TYPE:
740
ADDRESS:2752 MOHAWK CIRTELEPHONE:
(925) 719-9351
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 6CENSUS: 4DATE:
02/13/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Administrator, Niezen June ArcolasTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 02/13/2025 at 2:15 PM, Licensing Program Analyst (LPA) A. Gomez conducted a case management as a result of information obtained while conducting Annual inspection on todays date. LPA met with New Owner/ Administrator of Facility, Niezen June Arcolas and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory of which 1 may be bedridden.

While conducting the required annual LPA was informed that the Facility has been sold as of 8/30/2024 and is in the process of a change of ownership. LPA is requesting that current Licensee submit to CAB the change of ownership and process a change of Administrator with the regional office. LPA is also requesting a copy of the required notice provided to residents informing them of the change of ownership. LPA is also requesting a copy of the Lease back agreement (if available) along with the purchase agreement. LPA is requesting all documents to be sent by 2/20/2025.


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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