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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 11/18/2024
Date Signed: 11/18/2024 02:07:19 PM

Document Has Been Signed on 11/18/2024 02:07 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HEART AND SOUL COMMUNITIES IIFACILITY NUMBER:
019200476
ADMINISTRATOR/
DIRECTOR:		TILLIS, ERICKAFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 927-8046
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 6CENSUS: 9DATE:
11/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Ericka Tillis, Licensee TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On this day, November 18, 2024 at 1:25 am, Licensing Program Analyst (LPA) Clancy-Czuleger arrived unannounced to conduct case management inspection as part of monitoring plan from Non-compliance Conference held on November 07, 2024. LPA met with Licensee Ericka Tillis, and informed the reason for visit.

LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms, front, side and backyard. LPA inspected the food supples and observed good for 2 days of perishables and 7 days of non-perishables. During the health and safety check, LPA observed a total of 2 staff members and 9 residents at the facility. LPA confirmed that residents were served notices.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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