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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201257
Report Date: 08/01/2024
Date Signed: 08/01/2024 01:11:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
04/11/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240411112652
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: 6DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Maria ArceoTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Illegal eviction
Staff did not provide adequate food service
INVESTIGATION FINDINGS:
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13
On 8/1/2024 at 12:00 PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced deliver findings in regards to the allegations above. LPA met with Administrator, Maria Arceo and explained the purpose of the visit.

During the investigation LPA obtained a copy of an eveiction letter that was issued illegaly. LPA also conducted interviews in regards to what residents eat at meals and found that meals were not adequate.


Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
04/11/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240411112652

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: 6DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Maria ArceoTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Staff did not provide a comfortable environment for resident
INVESTIGATION FINDINGS:
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5
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7
8
9
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12
13
On 8/1/2024 at 12:00 PM, Licensing Program Analyst (LPA) A Gomez arrived unannounced deliver findings in regard to the allegations above. LPA met with Administrator, Maria Arceo and explained the purpose of the visit.

Throughout investigation LPA observed a comfortable environment for residents. LPA was unable to identify a time when the facility was not a comfortable enviroment.

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.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20240411112652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 DANVILLE
FACILITY NUMBER: 079201257
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2024
Section Cited
CCR
87224(a)
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(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)
This requirement is not met as evidence by:
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By POC date administrator agrees to review the regulation and notify CCLD.
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Based on record review and interview the licensee did not comply with the regulation above by issuing an eviction letter because the resident was unhappy with the service which posed a personal rights violation to person in care.
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Type B
08/02/2024
Section Cited
CCR
87464(f)(3)
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(f) Basic services shall at a minimum include:(3)Three nutritionally well-balanced meals...General Food Service Requirements.

This requirement is not met as evidence by:
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Administrator has retrained staff on what a balanced meal is.
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Based on interviews and record review the licensee did not comply with the regulation above by not providing 3 balanced meals daily which posed a potential health risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3