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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601242
Report Date: 06/06/2022
Date Signed: 06/06/2022 10:10:28 AM


Document Has Been Signed on 06/06/2022 10:10 AM - 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:HEART & SOUL COMMUNITIESFACILITY NUMBER:
015601242
ADMINISTRATOR:TILLIS, ERICKAFACILITY TYPE:
740
ADDRESS:3770 SUTER STREETTELEPHONE:
(510) 927-8046
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:6CENSUS: 0DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ericka Tillis, AdministratorTIME COMPLETED:
10:15 AM
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On 5/3/22 at 1:35pm LPAs K.Nguyen and C. Lin arrived unannounced to conduct Infection Control Inspection. LPAs spoke with Administrator Ericka Tillis via phone. AD stated there are no resident, and LPAs schedule for a time to come back.

On 5/19/22 at 9am LPAs K. Nguyen and C. Lin arrived for the appointment to do a health and safety inspection, due to facility have no Ct's. When arrived no one was here. LPAs spoke with Ericka via phone. She indicated that she can not make it out, due to her back injury. LPAs reschedule another appointment for a time to come back. LPAs left the facility at 9:30am.

On 06/06/2022 at 9:00 am Licensing Program Analyst (LPAs) K. Nguyen and C. Lin arrived for a Health and Safety Check. LPAs met with Ericka Tillis, Administrator.

During the visit LPAs observed that there are currently no resident residing at the facility. LPAs checked Carbon Monoxide detector, Smoke Detector, and Emergency Exits.

LPAs Recommend:

- Administrator purchase a Fire Extinguisher at the facility.


Exit interview conducted. A copy of this report provided to Administrator..

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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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