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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200695
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:59:39 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/01/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20240801154138
FACILITY NAME:GOOD SHEPHERD VISTAFACILITY NUMBER:
019200695
ADMINISTRATOR:KOO, HASMINFACILITY TYPE:
740
ADDRESS:5472 FOOTHILL BLVDTELEPHONE:
(510) 534-5734
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:22CENSUS: DATE:
08/08/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not follow proper emergency procedures as necessary.
INVESTIGATION FINDINGS:
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On 8/08/24 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Hasmin Koo and explained the purpose of the visit.

During the investigation LPA interviewed the reporting party (RP) S1, S2, and R1.

LPA interviewed S1. S1 stated that there is one awake overnight staff at the facility. On the morning of 7/28/24 S1 identified the staff on duty was S2. S1 also identified the resident who called 911 as R1. S1 stated that R1 is very independent and manages her affairs. R1 has a long history of calling 911, without telling the staff, from her private cell phone for minor ailments. On the morning of 7/28/24 R1 called 911 because she had a headache.

***report continues on LIC9099C***


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
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 2
Control Number 15-AS-20240801154138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GOOD SHEPHERD VISTA
FACILITY NUMBER: 019200695
VISIT DATE: 08/08/2024
NARRATIVE
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***report continues from LIC9099***

LPA interviewed S2 who stated he was on duty but not feeling well on the morning of 7/28/24 and was in the bathroom when Oakland Fire arrived at the facility. He estimates that it took him several minutes to get to the front gate. When he arrived there, he found the egress alarm had been triggered and saw R1 with Oakland Fire personnel being evaluated. S2 stated that Oakland Fire took R1 to Alta Bates ER to be evaluated.

LPA interviewed R1 who was in her bedroom at the facility. LPA observed that R1 had a cell phone on her night table. LPA asked R1 how she was feeling and R1 replied that she was “fine.” LPA asked R1 about calling 911. R1 stated that she calls 911 on her own because she “doesn’t want to bother the staff.” R1 had no complaints about her care at the facility.

This agency has investigated the complaint alleging staff did not follow proper emergency procedures as necessary. We have found that the complaint was 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.



Exit interview conducted, a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2