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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 09/22/2021
Date Signed: 09/22/2021 06:00:21 PM

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 AND SOUL COMMUNITIES IIFACILITY NUMBER:
019200476
ADMINISTRATOR:GEORGE ANDRE SMITHFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 686-1567
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:6CENSUS: 9DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ericka Tillis, Administrator/LicenseeTIME COMPLETED:
06:25 PM
NARRATIVE
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On 09/22/2021 at 12:30pm, Licensing Program Analysts (LPAs) L. Francisco and L. Hall arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPAs met with Care Staff, Gwen Green. Administrator/Licensee, Ericka Tillis later arrived at 1:00pm.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and outdoor area. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff.

The following deficiencies were observed:
-At 12:55pm, LPAs observed 9 residents at the facility.
-At 2:00pm during record review of R1's physician's report, LPAs observed R1 is non-ambulatory

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.

An immediate $1,000 civil penalty is being assessed.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HEART AND SOUL COMMUNITIES II
FACILITY NUMBER: 019200476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87158(a)
(a) A license shall be issued for a specific capacity which shall be the maximum number of residents which can be provided care at any given time. The capacity shall be exclusive of any members of the licensee's own family who reside at the facility. However, the licensing agency shall consider the presence of other family members or other persons who reside in the facility...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPAs observed 9 residents at facility. S1 stated 3 residents are from S1's other licensed facility and stays at this facility during the day which poses an immediate health, safety to persons in care.
POC Due Date: 09/23/2021
Plan of Correction
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By POC date, Administrator agrees to review regulation and send self-certification letter to CCL.

An immediate $500 Civil Penalty is being assessed.
Type A
Section Cited
CCR
87202(a)(1)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

(1) Nonambulatory persons.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review of R1's physician's report, the licensee did not comply with the section cited above. LPA observed R1 is non-ambulatory which poses an immediate health, safety risk to persons in care.
POC Due Date: 09/23/2021
Plan of Correction
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By POC date, Administrator agrees to submit a LIC 200 and floor plan to CCL.

An immediate $500 civil penalty is being assessed.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2021
LIC809 (FAS) - (06/04)
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