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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201257
Report Date: 05/28/2025
Date Signed: 08/12/2025 09:06:32 AM

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
09/10/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240910163010
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: 6DATE:
05/28/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH: Administrator, Isagani SilvestreTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff not changing residents in timely manner
Staff neglecting resident resulting in pressure injuries
Staff not responding to resident calling for help in a timely manner
Facility does not provide privacy to residents in care
Staff verbally abusing resident
INVESTIGATION FINDINGS:
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***This is an amended report***

On 8/12/25 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver amended findings for the above allegation. LPA met with Administrator, Isagani Silvestre and explained the purpose of the visit.


During course of the investigation, the Department conducted interviews with facility staff and witnesses. Documents including but not limited to: R1’s medical records, care notes, photos of resident, and admission agreements were collected and reviewed.


Report continues on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
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 9
Control Number 15-AS-20240910163010
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
VISIT DATE: 05/28/2025
NARRATIVE
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pg 2

On the allegations Staff not changing residents in timely manner, Staff neglecting resident resulting in pressure injuries, and Staff not responding to resident calling for help in a timely manner the following information was gathered: On 9/19/2024 a subpoena was served to Ace Home Health for R1’s medical records. The records revealed that between 1/23/2024 and 9/18/2024 R1 experienced worsening pressure injuries from lack of care and infrequent diaper changes by the facility staff. A care plan dated 10/31/2023 also stated that R1 is to have a call button and requires assistance with Activities of Daily Living (ADL’s). On 7/15/2024 W1 documented “R1 is left in soiled adult diapers during the night leading to severe excoriation of the skin and worsening of pressure injuries. Staff do not consistently respond to R1’s calls for assistance in a timely manner.” W1 also documented that they previously provided detailed instructions for staff to reposition R1 every 1-2 hours and promptly change R1’s diapers after incontinence; however, staff failed to consistently follow these instructions. W1 stated “I have repeatedly told the facility staff that R1 cannot sit in a wet diaper. It exacerbates R1’s skin injuries. They (staff) tell R1 that they will “get to it” but R1 ends up sitting in their waste for hours. R1 skin was bloody and raw on multiple occasions. W1 further explained that R1’s sacral pressure injury progressed to a stage 3 due to prolonged moisture exposure. W1 also noted that R1’s condition improves when wound care staff intervene, but the facility staff revert to neglectful care shortly after.

R1 stated in interviews that sometimes they ring their call bell, and no staff come for hours. R1 states that once they had to wait so long that they started crying from sitting in their own waste. R1 states that staff tell them to “stop yelling because they are not an animal” R1 reported delays in assistance occurring particularly during night shifts and further described the pain they experience from sitting in their waste.


Report Continues on LIC9099-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 15-AS-20240910163010
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
VISIT DATE: 05/28/2025
NARRATIVE
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pg 3

S1 stated that they estimate that R1’s diapers are changed about 12-18 times a day, but that staff relies on R1 to tell staff when they need to be changed, and that staff do not proactively check on R1. S1 admitted that there could be delays stating “Sometimes we(staff) are busy with other residents so there might be a delay, but we(staff) eventually get to R1.” S1 confirmed that staff were aware of R1’s need for frequent diaper changes.

In the interview with S2 they denied being informed of delays in R1 being changed and the fact that R1 had pressure injuries. However, when S2 was presented with documentation of R1’s notes detailing the instructions for R1 from the wound care they stated that, “This should have not happened if proper care was provided” S2 also denied knowing of the notes left for R1’s pressure injuries

S3, S4, and S5 all had similar account when it came to the frequency of changing R1 stating that they are changed on average 10 times a day but did wait for R1 to request being changed. Staff also all alluded to R1 “requiring a lot of attention” and that they were not always able to assist immediately.

Based on the interviews, medical records, wound care notes and photos it was found that delays in providing incontinence care directly contributed to the progression of R1’s pressure injuries. While staff claimed to respond “eventually” the lack of proactive care and reliance on R1 to request assistance demonstrates systemic neglect. The facility failed to ensure adequate staffing or adherence to care instructions, resulting in preventable harm to R1. Therefore, the allegations of Staff not changing residents in timely manner, Staff neglecting resident resulting in pressure injuries, and Staff not responding to resident calling for help in a timely manner are Substantiated.

Report Continues on LIC9099-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 15-AS-20240910163010
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
VISIT DATE: 05/28/2025
NARRATIVE
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pg 4 Amended

On the allegation "Facility does not provide privacy to residents in care" during the course of the investigation it was found during interviews when CCLD comes to visit the staff will question the residents as to what they talked about with LPA's or Investigators. It was observed during the investigation that staff went to question R1 after speaking with the Investigator and that the Investigator had to advice staff that all interviews are confidential. Based on interviews and observations the allegation "Facility does not provide privacy to residents in care" is Substantiated.

On the allegation of “Staff verbally abusing resident” 3/19/2025 LPA interviewed staff S2 and S6 on 3/19/202 that stated that they do not use profanity, call residents’ names, or yell at residents. S2 admitted to sometimes raising their voice when residents are yelling at them and making accusations that they deemed untrue. S2 emphasized that they do not yell at clients but that when clients are upset their tone elevates when trying to reason with residents. Therefore the allegation “Staff verbally abusing resident” is substantiated.

****A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.****


The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22. Substantiated findings will be reviewed for possible enhanced civil penalty assessment.

Exit interview conducted and a copy of this report provided.

***Caregiver, Cynthia Caudill was approved by administrator to sign todays amended report***
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 15-AS-20240910163010
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: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2025
Section Cited
CCR
87625(b)(3)
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(b)In addition … the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry … from incontinence

This requirement was not met as evidence by:
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Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment. Also facility agrees to maintain a log of all incotinence care provided with times and dates.
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Based on interviews and record review the facility did not comply with the section cited above by not keeping R1 clean and dry from incontinence which posed a potential health , and personal rights risk to persons in care.
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Type B
06/04/2025
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met as evidence by:
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Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment. Facility also hired additional staff and agrees to send CCLD an updated staff schedule.
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Based on interviews the facility did not comply with the section cited above by not having adequete staff to respond to residents needs in a timely manner which posed a potential health, and 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: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 15-AS-20240910163010
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: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2025
Section Cited
CCR
87468.2(a)(1)
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(a)In addition … residents …shall have all of the following personal rights:(1)To have …personal privacy in… communications…and meetings of resident and family groups.

This requirement was not met as evidence by:
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Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment.
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Based on interviews and observation the facility did not comply with the section cited above by not providing privacy to residents which posed a potential personal rights risk to persons in care.
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Type B
06/04/2025
Section Cited
CCR
87468.1(a)(3)
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(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, …

This requirement was not met as evidence by:
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Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment.
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Based on interviews the facility did not comply with the section cited above by speaking inappropriately to residents which posed a potential 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: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 15-AS-20240910163010
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: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/04/2025
Section Cited
HSC
1569.269(a)(6)
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(a) Residents... have all of the following rights: (6) To care, ...that meet their individual needs ... by staff that are...competency to meet their needs.

This requirement was not met as evidence by:

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Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment.

Resident was sent out to hospital and returned once injuries got better.
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Based on interviews, record reviews, and observations the facility did not comply with the section cited above by not providing resident with competent care which resulted in pressure injuries which posed an immediate health, and 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: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 9
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
09/10/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240910163010

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: 6DATE:
05/28/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Backup Administrator, Merdith CastroTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff physically abuses residents in care
Staff does not allow residents access to phone
INVESTIGATION FINDINGS:
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On 5/08/2025 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver findings for the above allegation. LPA met withBackup Administrator, Merdith Castro and explained the purpose of the visit.

During course of the investigation, the Department conducted interviews with facility staff and witnesses. Documents including but not limited to: R1’s medical records, care notes, photos of resident, and admission agreements were collected and reviewed.

Report Continues on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 15-AS-20240910163010
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
VISIT DATE: 05/28/2025
NARRATIVE
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On the allegations Staff physically abuses residents in care, and Staff does not allow residents access to phone interviews and observations were conducted. Throughout the course of the investigation it was found that the facility has a phone that is available to residents and that it is operational with service. It was observed on 3/19/2025 that the primary phone is located in the kitchen on the table and is cordless allowing residents to take the phone throughout the facility. During the investigation the LPA did not observe any residents with bruises or scratches. LPA interviewed staff and did not find any inclination of physical abuse. LPA was unable to interview additional residents due to their cognitive abilities. Based on interviews and observations the above allegations are Unsubstantiated.


Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 9 of 9