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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201257
Report Date: 08/01/2024
Date Signed: 08/13/2024 03:23:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240723151436
FACILITY NAME:GOOD SHEPHERD OF DANVILLEFACILITY NUMBER:
079201257
ADMINISTRATOR:CASTRO, ROCHEFACILITY TYPE:
740
ADDRESS:287 VERDE MESATELEPHONE:
(925) 719-9351
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Maria ArceoTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility is in disrepair
Staff restrained resident in their bed
INVESTIGATION FINDINGS:
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On 8/01/2024 at 12:00 a.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Administrator, Maria Arceo and explained the purpose of the visit. Census is 6. Administrator was unavailable to resign and Caregiver, Rommel Dimzon signed report.

During the visit LPA obtained copies of the physicians reports/orders for R1, and R2. LPA also toured the facility and observed dryer in disrepair with out of order sign. Staff currently dries clothes outside on line. LPA received photos of R1 improperly restrained in bed with a red white and blue strap that was tied on bed bars.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20240723151436
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GOOD SHEPHERD OF DANVILLE
FACILITY NUMBER: 079201257
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2024
Section Cited
CCR
87608(a)(2)
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(a) Based on the individual's preadmission appraisal,... Postural supports may be used under the following conditions.(2) Postural supports shall... permits quick release by the resident.
This regulation is not met as evidence by:
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Administrator has requested the correct support from the doctor and has stopped using the improper restraint.
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Based on interview and photos R1 was restrained in bed by a strap that was tied to bedrails which posed a potential health and personal rights risk to person in care.
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Type B
08/09/2024
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This regulation is not met as evidence by:
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By POC date administrator agrees to purchase a new dryer and notify CCLD.
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Based on observation the dryer has an out of order sign and does not properly work. Staff has been hang drying clothes outside which poses a potental personal rights risk to persons in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2