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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 10/10/2024
Date Signed: 10/10/2024 10:26:06 AM

Document Has Been Signed on 10/10/2024 10:26 AM - 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:		GEORGE ANDRE SMITHFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 927-8046
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 6CENSUS: 7DATE:
10/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Ericka Tillis, LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
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On 10/10/2024 at 08:30 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger and J. Sampair arrived unannounced to conduct a Case Management. LPA met with Ericka Tillis, Administrator.

While at the facility on 10/07/2024 LPA J. Sampair observed that there were 11 residents in the care facility. S1 stated that only 6 were residents of this home and the other 5 were residents for the other home Heart and Sol Communities (15601242) that's located at 3770 Sutter st. Oakland. When arriving at the facility on 10/10/2024 LPA's were informed by staff that they had 7 residents.

It was also observed that there were chemicals left under the upstairs kitchen sink and bathroom sink unlocked and accessible to residents.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809D's. A $250.00 civil penalty is assessed for each of the repeat violation of deficiency section #'s 87204(a) and 87309(a). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Exit interview conducted. Appeal Rights, LIC421FC, and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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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Document Has Been Signed on 10/10/2024 10:26 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 10/10/2024 at 08:59 AM
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: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2024
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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A mandatory meeting will be held at a later date.

This is a repeat violation of the same citation issued by LPA J. Clancy-Czuleger on 09/10/2024
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On 10/07/2024 LPA's observed 6 residents, and 5 visiting residents at the care facility being cared for. On 10/10/2024 LPA's were
informed that there are 7 residents.
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Type B
10/17/2024
Section Cited
CCR87309(a)

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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by…
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This is a repeat violation of the same citation issued by LPA J. Clancy-Czuleger on 09/10/2024 and by LPA J. Sampair on 09/24/2024.

A civil penalty of $250 is being assessed for this repeat violation
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On 10/07/2025 LPAs's observed chemicals left unlocked and accessible under the upstairs kitchen sink and bathroom sink.
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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
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