<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201257
Report Date: 05/14/2024
Date Signed: 05/14/2024 02:24:59 PM

Document Has Been Signed on 05/14/2024 02:24 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 DANVILLEFACILITY NUMBER:
079201257
ADMINISTRATOR/
DIRECTOR:		CASTRO, ROCHEFACILITY TYPE:
740
ADDRESS:287 VERDE MESATELEPHONE:
(925) 719-9351
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 6CENSUS: DATE:
05/14/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Caregiver, Hope VeneracionTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/14/2024 at 9:25 AM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of an unusual incident report received 5/9/2024. LPA met with Caregiver, Hope Veneracion and explained the purpose of the visit. Administrator later arrived.

On 5/9/2024 CCLD received an unusual incident report stating that a resident (R1) left the facility unassisted and was not found in their bedroom at approximately 8:30AM when facility staff went to get them ready for the day. Danville Police department was notified and a search for R1 was conducted. Administrator stated that resident disabled the door alarm and exited through kitchen door. Administrator also stated that facility staff (S2) saw the resident last at approximately 3:45AM when the resident went to the bathroom. On 5/13/2024 resident was located and transferred to Contra Costa Regional Center. Resident is reported to have been located without any physical injuries.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 111 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 in the kitchen. Smoke detectors and carbon monoxide detectors were observe. First-aid kit was complete. Fire extinguisher was purchased on 4/08/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. Door alarms were observed and were in working order during visit.


Report continues on LIC809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 05/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA interviewed S1, S2, Administrator, and R2. LPA also spoke with R1's regional social worker over the phone as well as a Danville police officer. LPA obtained copies of R1's needs and services plan, as well as the police report number associated with he incident. Administrator is to fax over staff training's for review.

During interview S1 stated that the kitchen door alarm was set at the end of their shift and they are unsure as to how it got turned off. S2 states that they also remember going over all door alarms with S1 and that they were set. S1 and S2 state that they are unsure if R1 would be able to reach the door alarm to disable it but that R1 observes staff closely and has attempted before to unlock other locks such as the medicine cabinet. S2 also states that they saw R1 go to the bathroom around 3:45am.

During interview with R2 they stated that they did not hear R1 on the morning of elopement. R2 states that R1 has attempted to exit facility before and frequently walks around at night checking to see what doors are unlocked. R2 states that they did not hear any alarm go off on the day of elopement.

During phone interview with R1's regional social worker LPA was informed that R1 has a history of elopement. Social worker states that R1 has "sneaky" behavior and has in the past been know to observe staff and use that as a means to elope or do other dangerous behaviors. Social worker stated that R1 has had psych evaluations that show that R1 is high functioning but lacks the cognitive abilities to think out the consequences of their actions.


Report continues on LIC809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 05/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During phone interview with Danville police officer LPA learned that it is estimated that R1 eloped from the facility around 6:00-7:00AM. R1 is suspected to have left in this time frame based on eye witnesses as well as an estimated walk time from facility to local bus stop. Officer advised LPA that R1 called their son who reported the call to police. Police then located R1 in Antioch and transferred R1 to a local hospital. R1 was observed to be lucid and without injury.

The following Deficiencies will be cited:
  • Adequate staffing/plan was not available to ensure that resident with elopement tendencies was properly addressed.

  • Staff training's are not readily available for review at facility



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/14/2024 02:24 PM - It Cannot Be Edited


Created By: Alona Gomez On 05/14/2024 at 01:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GOOD SHEPHERD OF DANVILLE
FACILITY NUMBER: 079201257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2024
Section Cited
CCR
87411(a)

1
2
3
4
5
6
7
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...require such additional staff for the provision of adequate services.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
By POC date administrator has agreed to install cameras to help monitor residents and will provide additional dementia training and submit proof of training's in accordance with regulations to CCLD
8
9
10
11
12
13
14
Based on report of resident with previous elopement behavior eloping from facility the staff were not competent in how to address the behavior and prevent the resident from being missing for days.
8
9
10
11
12
13
14
Type B
05/21/2024
Section Cited
CCR87412(g)

1
2
3
4
5
6
7
All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.


This requirement is not met as evidence by:
1
2
3
4
5
6
7
By POC date administrator has agreed to provide all trainings and keep the training logs available at facility to meet regulation standards and notify CCLD
8
9
10
11
12
13
14
Administrator did not have training records readily available for review upon LPA's request
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4