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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200847
Report Date: 09/08/2023
Date Signed: 09/08/2023 12:41:58 PM


Document Has Been Signed on 09/08/2023 12:41 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 DUBLIN, THEFACILITY NUMBER:
019200847
ADMINISTRATOR:CASTRO, MERDITHFACILITY TYPE:
740
ADDRESS:8206 RHODA AVETELEPHONE:
(925) 895-2569
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:6CENSUS: 4DATE:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Isagani Silvestre, AdministratorTIME COMPLETED:
01:00 PM
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On 9/08/23 at 9:15 a.m., Licensing Program Analyst (LPA) Kelly Nguyen arrived unannounced to conduct one year annual Inspection. LPA met with Lester, Care Staff and explained the purpose of the visit. Later Isagani Silvestre arrived at 9:40am.

LPA inspected the facility including but not limited to, bedrooms, living room, kitchen, dining room and outdoor areas. There are five bedrooms and 3 bathrooms. Sufficient furniture and lighting throughout facility. Bathroom/shower areas are equipped with grab bars and nonskid mats. Bathrooms/hallways equipped with night lights. Two-day perishable and seven-day non-perishable food supply observed. Hot water temperature in resident's bathroom measured 116 degrees F. Facility maintained a temperature of 73 degrees F. Emergency exits and passageways free of obstruction. Centrally stored medications, toxins and sharps stored in locked cabinets. First Aid Kit, Fire Extinguishers, carbon monoxide, smoke detectors are present. LPA reviewed 4 resident and 4 staff files. Centrally stored medication records were reviewed for four residents.

No corrections or deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
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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