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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201257
Report Date: 09/12/2024
Date Signed: 09/12/2024 06:32:07 PM

Document Has Been Signed on 09/12/2024 06:32 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: 6DATE:
09/12/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:45 PM
MET WITH:Administrator, Merdith CastroTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 9/12/2024, at 4:45PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Administrator, Merdith Castro, and explained the purpose of the visit.

LPA conducted an annual inspection on 8/28/2024 and cited for the following deficiencies that has not been corrected.

  • 87202(a)(2)- LPA observed resident in room 5 is still designated as bedridden and is not on hospice. Only room 2 is cleared for bedridden and facility is only cleared for 1 bedridden resident.


***Civil Penalty 100 day X 7 days= $700

    Civil Penalties in the total amount of $700.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiencies are corrected.

    Exit interview conducted. A copy of this report, LIC421FC, and appeal rights provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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Document Has Been Signed on 09/12/2024 06:32 PM - It Cannot Be Edited


Created By: Alona Gomez On 09/12/2024 at 05:07 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: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2024
Section Cited
CCR
87202(a)(2)

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(a) All facilities shall maintain a fire clearance approved by the city, county, ..., or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
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Administrator agrees to put resident on hospice or find new placement for resident.
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Based on observation and record review, the licensee did not comply with the section cited above in having two bedridden residents and one of the residents is in room 5 that is not cleared for bedridden which poses an immediate health, safety 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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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