Facility Evaluation Report

Good Samaritan Residential Care Facility, Hayward05/22/2024Licence 019200020

Capacity6
Census6
Date signed05/22/2024 03:15:39 PM
The inspector’s account

On 5/20/2024, Licensing Program Analyst (LPA) Kelly Nguyen conducted an unannounced case management regarding an incident report (sexual abuse) received by CCL and met with staff Ellen Jovero. LPA informed staff and Administrator, Frank (via telephone) that the case management is being conducted. Frank was unable to be here and gave verbal permission to Ellen to sign the report.

LPA obtained and reviewed physician's report for Client 1 (C1). LPA interview S1, S2, and S3 regarding the unusual incident report. Physician's Reports for C1 indicate that they are ambulatory and cannot leave the facility unassisted. C1 ended up in the hospital by the ambulance due to behavior. After being evaluated by the hospital C1 was discharge back to the facility by non-emergency ambulance. C1 refused to get off gurney and Hayward Police got involved. C1 was brought to St. Rose Hospital. LPA interviewed C1, C1 was uncleared of the story or time line when incident occurred. After the incident S3 stated that C1 is continuing to be supervised by staff 24/7.

There is no deficiency noted on this day.

Copy of this report provided to Administrator via e-mail.

Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction