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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201257
Report Date: 04/09/2024
Date Signed: 04/09/2024 04:13:21 PM

Document Has Been Signed on 04/09/2024 04:13 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:
04/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:Caregiver, Hope VeneracionTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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On 04/0/92024 at 3:50 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of CCLD receiving notification of Residents being relocated to facility due to a fire at another facility. LPA met with Caregiver, Hope Veneracion and explained the purpose of the visit. Administrator was unavailable.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 110.2 degrees F in the bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked. Smoke detectors are interconnected with the sprinkler system. A comfortable temperature was maintained at 77 degrees F. Carbon monoxide detector 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.

LPA spoke with R1 and R2 to see how they are adjusting to the facility. R1 and R2 have dementia and were unable to give coherent answers. Administrator has residents files at the facility and medications at the facility
No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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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