079201220-3-7-2024-15-AS-AGOZ-D35TG3-20240307134229

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201220
Report Date: 03/07/2024
Date Signed: 03/07/2024 01:42:38 PM

Document Has Been Signed on 03/07/2024 01:42 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 SAN RAMON		FACILITY NUMBER:	079201220
ADMINISTRATOR:	CASTRO, ROCHE		FACILITY TYPE:	740
ADDRESS:	2752 MOHAWK CIR		TELEPHONE:	(925) 719-9351
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 6	DATE:	03/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Backup Administrator, Isagani Silvestre		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/07/2024 at 10:00 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Backup Administrator, Isagani Silvestre and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory of which 1 may be bedridden. LPA toured facility with Isagani Silvestre including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 06/06/2023. Emergency Disaster Plan was last posted on 02/01/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 02/01/2024. At 10:40 am, LPA reviewed 5 residents records. At 11:30 am, LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. Report continues on LIC 809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SAN RAMON	FACILITY NUMBER: 079201220
	VISIT DATE: 03/07/2024

NARRATIVE

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The Following Deficiencies were Observed:

During Tour at 12:30PM LPA observed an enclosed structure with 2 rooms in the garage that are not identified on facility sketch. 1 room does appear to be utilized as a dwelling for staff
During Tour at 12:55PM LPA observed oxygen in use sign not posted for a resident (R4) that is utilizing oxygen in their room. Backup Administrator posted sign during visit.

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 03/31/2024:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
Updated Facility Sketch

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2024 01:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SAN RAMON	FACILITY NUMBER: 079201220
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87618(b)(3)(B)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having an oxygen in use sign posted on appropriate residents room entrance which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/08/2024
	Plan of Correction
1 2 3 4	Administrator Posted the sign during the visit deficiency cleared

Type B

Section Cited

CCR

87208(A)(7)

87208(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having an unspecified structure built in garage which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2024
	Plan of Correction
1 2 3 4	By POC date administrator agrees to remove structure or update the facility sketch and get the structure approved by the fire department if necessary.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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