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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 04/04/2025
Date Signed: 04/04/2025 06:39:43 PM

Document Has Been Signed on 04/04/2025 06:39 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: 8DATE:
04/04/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Licensee Ericka TillisTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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On 04/04/2025, at 2:30 PM, Licensing Program Analysts (LPAs) James Sampair and Yasamin Brown arrived unannounced to conduct a Case Management - Health Check inspection. Upon entering the facility, the LPAs explained the purpose of visit to Licensee Ericka Tillis.

The LPAs toured the facility with the Licensee. The LPAs inspected both floors of the facility, including both of the kitchens, dining areas, restrooms, community living spaces, bathrooms, resident rooms, and the grounds of the facility. Temperature in the upstairs kitchen was measured at 73.8 degrees Fahrenheit. Fire extinguisher was fully charged and last replaced on 02/11/2025. The combination carbon monoxide and smoke detector was fully operational.



The facility remains over capacity, care of persons classified as non-ambulatory in a facility licensed to care for ambulatory only persons, unpaid annual and late fees, and absence of a certified administrator.

In addition to the existing deficiencies listed above, 2 new Type-A and 2 new Type-B deficiencies, and a $500 Civil Penalty were issued during the visit (for details refer to LIC 809-D and LIC 421BG).



The exit interview was conducted and a copy of this report provided.


Facility is subject to ongoing daily civil penalties until proof of corrected deficiencies have been sent to Community Care Licensing (CCL).
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: James Sampair
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/04/2025 06:39 PM - It Cannot Be Edited


Created By: James Sampair On 04/04/2025 at 04:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2025
Section Cited
CCR
87555(b)(26)

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
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Licensee agreed to purchase food and submit photo and receipt to CCLD by POC date.
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Based on observation, the Licensee did not have a one week supply of nonperishable and 2 days of perishable foods maintained on the premises, which poses a potential health risk to persons in care.
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Type B
04/11/2025
Section Cited
CCR87555(b)(21)

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87555 General Food Service Requirements (b)(21) Freezers of adequate size shall be maintained at a temperature of 0-degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean, and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
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For all of the refrigerators and freezers in the facility, the Licensee agreed to reduce freezer temperatures to 0 degrees, the refrigerators to 40 degrees and attest to the proper temperature, and to thoroughly clean them. The Licensee shall submit the attestation and photos of every one after they have been cleaned to CCLD by POC date.
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The temperature of one of the freezers was 13.8 degrees and one of the refrigerators was 43.2 degrees Fahrenheit. All of the refrigerators and freezers were observed to be unclean.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/04/2025 06:39 PM - It Cannot Be Edited


Created By: James Sampair On 04/04/2025 at 05:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2025
Section Cited
CCR
1569.17(c)(1)(A)

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(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.
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Licensee promised to have S1 fingerprinted and associated with the facility on or before the due date.
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This requirement is not met as evidenced by:

Family member S1 living at the facility is 18 years old and did not have fingerprint clearance, which poses an immediate safety risk to persons in care.
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Type A
04/05/2025
Section Cited
CCR87465(h)(2)

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Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
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Licensee promised to put medications stored in refrigerator in a locked box on or before the due date.
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With medications stored unlocked in the refrigerators, the licensee did not comply with the section above, which poses an immediate safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2025


LIC809 (FAS) - (06/04)
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