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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201257
Report Date: 10/04/2023
Date Signed: 10/04/2023 04:52:45 PM

Document Has Been Signed on 10/04/2023 04:52 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 0DATE:
10/04/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Meredith Castro, Designee, TIME COMPLETED:
05:05 PM
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On 10/4/2023 at 4:00pm,, Licensing Program Analyst (LPA)L. Hall arrived unannounced to conduct a pre-licensing inspection. LPA met with Meredith Castro, designee and explained the purpose of the visit. The facility has an approved fire safety clearance for five (5) non-ambulatory and one (1) bedridden resident.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and back yard. The facility has a total of five (5) bedrooms, two (2) bathrooms. There were no bodies of water present during inspection. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with grab bars. Passageways and hallways are free of obstruction. Locked cabinets available to store medications and toxins. Locked cabinet to store sharps. Hot water temperature is measured at 114.3 degrees Fahrenheit. Fire extinguisher was last serviced on 12/1/2022. Carbon monoxide and smoke detectors present. First-Aid kit was observed complete.

Licensing Program Manager (LPM), H. Humpal gave approval to waive Comp III.

No issues were noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
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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