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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 01/29/2025
Date Signed: 01/29/2025 04:23:22 PM

Document Has Been Signed on 01/29/2025 04:23 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:		TILLIS, ERICKAFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 927-8046
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 6CENSUS: 7DATE:
01/29/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Licensee Ericka TillisTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 1/29/2025 at 10:30 AM, Licensing Program Analysts (LPAs) James Sampair and Jill Clancy-Czuleger arrived unannounced to conduct a Plan of Correction (POC) visit. Upon arrival, the LPAs stated the purpose of the visit to Licensee Ericka Tillis.

On 01/13/2025, LPA Sampair conducted a Case Management visit during which 4 deficiencies were cited. 1 deficiency was cleared during the visit. 3 of the deficiencies were not cleared during the visit: resident records missing, no emergency/disaster drill conducted, and the hot water temperature was measured at 133.7 degrees Fahrenheit.

Civil Penalties for deficiencies not cleared during visit:
  • Due 1/14/2025 for 87303(e)(2) 16 x $100 per day = $1,600
  • Due 1/14/2025 for 87506(a) 16 x $100 per day = $1,600
  • Due 1/27/2025 for 1569.695(c) 2 x $100 per day = $200


Civil Penalties in the total amount of $3,400 have been assessed today for failure to meet POC due dates for the deficiencies above. Facility is subject to ongoing daily civil penalties until proof of corrected deficiencies have been sent to CCL.

Exit interview conducted. A copy of this report, appeal rights, and LIC 421FCs provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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