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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 10/07/2024
Date Signed: 10/07/2024 02:40:05 PM

Document Has Been Signed on 10/07/2024 02:40 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 AND SOUL COMMUNITIES IIFACILITY NUMBER:
019200476
ADMINISTRATOR/
DIRECTOR:		GEORGE ANDRE SMITHFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 927-8046
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 6CENSUS: 11DATE:
10/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Caregiver Keiyata PettwayTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On 10/7/2024 at 1:30 PM, Licensing Program Analysts (LPAs) James Sampair and David Doidge conducted a Plan of Correction (POC) inspection. Upon entry into facility, LPAs explained the purpose of the visit to Caregiver Keiyata Pettway.

The Licensee failed to provide documentation to LPA Sampair on 3 of the 5 citations issued during the 9/24/2024 visit. Failure to send proof of correction to the LPA resulted in the issue of 3 civil penalties (for details, refer to the LIC 421FC forms).

Exit interview conducted and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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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