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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200476
Report Date: 01/13/2025
Date Signed: 01/13/2025 02:55:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
07/22/2024 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240722112140
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:
01/13/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator Ericka TillisTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff speak inappropriately to residents
Facility staff yell at residents
INVESTIGATION FINDINGS:
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On 1/13/2025 at 8:15 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to deliver finding for the above allegations and met with Licensee Ericka Tillis. LPA explained to Ms. Tillis the purpose of the visit.

During the course of investigation, LPA L. Fontanilla conducted the 10-day visit, obtained records and interviewed the Administrator, five residents, two staff and responsible persons for two residents.

On 7/29/2024, LPA Fontanilla spoke with the Reporting Party (RP) who states that RP did not physically witness but heard voices from the facility. RP added that the voice was saying, “Are you going to hurt me?” and a “Yes” response was heard. RP added that days after calling in the complaint to Community Care Licensing (CCL), RP observed a fire engine arrive and the facility has been quiet since then.

Continued on LIC 809-C . . .
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
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 2
Control Number 15-AS-20240722112140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/13/2025
NARRATIVE
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. . . Continued from LIC 809

Based on interviews conducted, 3 out of 5 residents denied observing staff yelling at residents. The Administrator and two staff interviewed denied yelling or speaking to residents inappropriately. The Licesee states that she takes care of a family member who has illness and needed to be picked up by an ambulance a few days before LPA visit.

On 10/14/2024, LPA interviewed responsible persons for R5 and R6, residents with a dementia diagnosis. Both RPs denied witnessing or hearing staff yelling and/or speaking inappropriately to the residents.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

There was no deficiency associated with this complaint.

A copy of this report was provided to the Licesee.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2