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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601242
Report Date: 10/21/2024
Date Signed: 10/21/2024 01:57:20 PM

Document Has Been Signed on 10/21/2024 01:57 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:HEART & SOUL COMMUNITIESFACILITY NUMBER:
015601242
ADMINISTRATOR/
DIRECTOR:		TILLIS, ERICKAFACILITY TYPE:
740
ADDRESS:3770 SUTER STREETTELEPHONE:
(510) 927-8046
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY: 6CENSUS: 0DATE:
10/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Licensee Ericka TillisTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 10/21/2024 at 7:30 AM, Licensing Program Analysts (LPAs) James Sampair and Ardalan Gharachorloo conducted a Case Management visit of the facility to verify that residents were living there, as the Licensee, Ericka Tillis, had stated to LPAs James Sampair and David Doidge during inspections of HEART AND SOUL COMMUNITIES II #019200476 on 9/24/2024 and 10/10/2024.

When the LPAs observed that there was no observable proof that any residents were living at the facility, the LPAs travelled to HEART AND SOUL COMMUNITIES II #019200476 for a Case Management visit to verify that residents from Heart & Soul Communities #015601242 were living living at HEART AND SOUL COMMUNITIES II #019200476 owned and operated by the same Licensee.

Upon entry into facility, HEART AND SOUL COMMUNITIES II #019200476, the LPAs explained the purpose of the visit to Licensee Ericka Tillis. The LPAs confirmed that the residents of this facility were no longer living at the facility and that they had been moved to facility HEART AND SOUL COMMUNITIES II #019200476 without notification to the Department.

Exit interview conducted, a copy of this report, and the appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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