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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 10/21/2024
Date Signed: 10/21/2024 01:55:46 PM

Document Has Been Signed on 10/21/2024 01:55 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:		GEORGE ANDRE SMITHFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 927-8046
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 6CENSUS: 11DATE:
10/21/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee Ericka TillisTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 10/21/2024 at 9:00 AM, Licensing Program Analysts (LPAs) James Sampair and Ardalan Gharachorloo conducted a Plan of Correction (POC) inspection. Upon entry into facility, LPAs explained the purpose of the visit to Licensee Ericka Tillis.

The Licensee failed to send documentation of POC clearance from the citation issued 10/10/2024 to LPA Sampair. During the inspection of the facility, the medications were in locked storage, however, the signage on the first and second floors was not posted.

Per Title 22 California Code of Regulations, a $1,100.00 Civil Penalty was assessed for the repeat of a prior violation of Section 87309(b) first issued on 9/24/2024 that was due on 10/11/2024. For additional details, refer to the LIC 421FC form. Failure to submit proof of corrections may result in additional civil penalties.

Exit interview conducted, a copy of this report, and the appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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 10/21/2024 01:55 PM - It Cannot Be Edited


Created By: James Sampair On 10/21/2024 at 10:42 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: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
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Licensee corrected during the visit.
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Based on observation, the licensee did not comply with the section cited above. A toilet seat had a large crack, which poses a potential health, safety or personal rights 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
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