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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 02/12/2025
Date Signed: 02/12/2025 05:49:23 PM

Document Has Been Signed on 02/12/2025 05:49 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: 9DATE:
02/12/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Licensee Ericka TillisTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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On February 12, 2025 at 3:30 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a Plan of Correction (POC) visit. Upon arrival, the LPA stated the purpose of the visit to Licensee Ericka Tillis.

On January 29, 2025, LPAs Clancy-Czuleger and Sampair conducted a Case Management visit during which 7 deficiencies were cited. 1 deficiency was cleared during the visit. 6 of the deficiencies were not cleared during the visit.

Civil Penalties for deficiencies not cleared during visit:

· Due 1/31/25 for CCR 87204(a): 14 days at $100 per day totals $1,400 – Over Capacity


· Due 1/31/25 for CCR 87355(d): 12 days at $100 per day totals $1,200 – No Certified Administrator Present
· Due 1/31/25 for CCR 87204(b): 14 days at $100 per day totals $1,400 – Care of Persons Classified as Non-Ambulatory in Ambulatory Only Facility
· Due 1/31/25 for CCR 87705(c)(1): 14 days at $100 per day totals $1,400 – Care of Persons with Dementia in Ambulatory Only Facility
· Due 1/31/25 for HSC 1569.185(a)(1): 12 days at $100 per day totals $1,200 – Payment of Annual Fees 2019-2024
· Due 1/31/25 for HSC 1569.185(b)(1)(F): 12 days at $100 per day totals $1,200 – Payment of Late Fees 2019-2024

Civil Penalties totaling $7,800 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 Community Care Licensing (CCL).

Continued on LIC 809-C…

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 019200476
VISIT DATE: 02/12/2025
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...Continued from LIC 809

Deficiencies are cited from Title 22 California Code of Regulations (see 809D's). Failure to submit proof of correction along with the LIC9098 Proof of Correction by due date may result in additional civil penalty.

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: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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