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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200476
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:20:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240514153218
FACILITY NAME:HEART AND SOUL COMMUNITIES IIFACILITY NUMBER:
019200476
ADMINISTRATOR:GEORGE ANDRE SMITHFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 686-1567
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:6CENSUS: 9DATE:
09/10/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ericka Tillis, LicenseeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not ensure they were not over capacity
Staff are commingling residents
Staff did not prevent resident from wandering from the facility
Staff are not providing adequate food service to residents
INVESTIGATION FINDINGS:
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On 09/10/2024 at 11:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator Ericka Tillis.

On the allegations: On the allegation Staff did not ensure they were not over capacity and Staff are commingling residents. While at the facility on 5/16/24, LPA observed 4 staff members, and 9 seniors at the facility. Licensee stated that 6 were residents and were 3 visitors who are from her other home at 3770 Suter Street Oakland, 94619. On 9/10/24 LPA observed 9 seniors 6 were residents and were 3 visitors.

On the allegation On the allegation Staff did not prevent resident from wandering from the facility. R1 went missing from the facility on 5/1424. R1 was found by the police and returned to the facility.

Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20240514153218

FACILITY NAME:HEART AND SOUL COMMUNITIES IIFACILITY NUMBER:
019200476
ADMINISTRATOR:GEORGE ANDRE SMITHFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 686-1567
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:6CENSUS: 9DATE:
09/10/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ericka Tillis, LicenseeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
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3
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7
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9
Staff allowed a minor to provide care for residents
Staff are not locking up medications
Resident fell sustaining injuries resulting in death due to staff neglect
Staff are mismanaging residents medication
INVESTIGATION FINDINGS:
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On 09/10/2024 at 10:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Licensee Ericka Tillis.

On the allegation On the allegation Staff allowed a minor to provide care for residents. S1 states that she does have a daughter who lives at the facility but states that she does not provide care to the residents.

On the allegation On the allegation Staff are not locking up medications. While at the facility on 5/16/24, LPA observed the medication cabinet to be locked and inaccessible to residents.

On the allegation On the allegation Staff are mismanaging residents medication, LPA observed the medication logs for each resident. S1 stated that they log each dose that is given and if a medication error occurs they contact the reisidents PCP and report it to CCLD.
Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20240514153218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 019200476
VISIT DATE: 09/10/2024
NARRATIVE
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...Continued from 9099A

On the allegation Resident fell sustaining injuries resulting in death due to staff neglect. The incident happened in 2018, and the facility no longer has the documentation for this resident. S1 stated that they are only required to keep resident records for three years after a resident passed, so they no longer have R2 documents.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20240514153218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 019200476
VISIT DATE: 09/10/2024
NARRATIVE
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...Continued from 9099

On the allegation Staff are not providing adequate food service to residents. It was observed that there was a potato that had been eaten by a rodent in the kitchen.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited.



Exit interview conducted. A copy appeal rights, and this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 15-AS-20240514153218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 019200476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2024
Section Cited
CCR
87705(j)
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The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by
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The Licensee agrees to review the regulation and a letter of self certification to CCLD by POC date.
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R1 AWOLing from the facility on 5/14/24 and no devices were in place at tht time.
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Type B
09/17/2024
Section Cited
CCR
87555(b)(9)
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(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.This requirement is not met as evidenced by
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The Licensee argees to clean out the residents kitchen, and reorganize to protect saftey in food storage. Proof of correction will be sent to CCLD by POC date.
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It was observed that there was a potato that had been eaten by a rodent in the kitchen.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20240514153218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 019200476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2024
Section Cited
CCR
87204(a)
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A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time... This requirement is not met as evidenced by…
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The Facility agrees to relocate the additional residents from the facility. Proof of correction will be sent to CCLD by POC date.
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LPA observed 6 residents, and 3 visiting residents at the care facility being cared for.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6