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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 01/13/2025
Date Signed: 01/13/2025 03:19:16 PM

Document Has Been Signed on 01/13/2025 03:19 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: 9DATE:
01/13/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Administrator Ericka TillisTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 1/13/2025 at 8:15 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a Case Management inspection as part of the monitoring plan from Non-compliance Conference held on November 07, 2024 with Licensee Ericka Tillis. Upon arrival, the LPA informed the Licensee of the reason for visit.

The LPA inspected the interior and exterior of the facility, including the kitchens upstairs and downstairs, the dining room areas, community living spaces, restrooms, resident rooms, storage areas, the garage, and the grounds of the facility.

There was more than the required minimum of 2 days of perishable and 7 days of nonperishable food at the facility. The hot water temperature was measured in the upstairs kitchen at 137.3 degrees Fahrenheit (Type-A Citation). The upstairs dining room temperature was measured at 70.0 degrees Fahrenheit. The fire extinguisher was last serviced on 10/30/2023 (Type-B Citation).

LPA observed a total of 3 staff members and 9 residents at the facility.


Continued on LIC 809-C
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.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 01/13/2025 03:19 PM - It Cannot Be Edited


Created By: James Sampair On 01/13/2025 at 01:12 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: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2025
Section Cited
CCR
87303(e)(2)

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87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) … Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to … not less than 105 degree F … and not more than 120 degree F.

This requirement is not met as evidenced by:
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On or before the due date, the Licensee shall send proof to the LPA that the temperature of the hot water has been reduced to between 105 and 120 degrees Fahrenheit.
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Based on observation, the licensee did not comply with the section cited above. The hot water temperature was measured at 137.3 degrees Fahrenheit, which poses an immediate 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: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/13/2025 03:19 PM - It Cannot Be Edited


Created By: James Sampair On 01/13/2025 at 01:51 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: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2025
Section Cited
CCR
87203

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87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
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On or before the due date, the Licencee shall send proof to the LPA that the fire extinguisher has been serviced or replaced.
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Based on observation, the licensee did not comply with the section cited above. The last time the fire extinguisher was serviced was 10/30/2023, beyond the annual inspection time limit, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/27/2025
Section Cited
HSC87506(a)

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
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On or before the due date, the Licencee shall send conservator names and contact information for each conservator, along with copies of the eviction letters, so the LPA will be able to call to confirm and to establish possible dates by when the non-ambulatory residents will be leaving the facility.
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Based on record review, the Licensee did not comply with the section cited above. A separate, complete, and current record for each resident in the facility is not readily available to licensing agency staff, 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: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


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Document Has Been Signed on 01/13/2025 03:19 PM - It Cannot Be Edited


Created By: James Sampair On 01/13/2025 at 02:13 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: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2025
Section Cited
HSC
1569.695(c)

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1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter ... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill

This requirement is not met as evidenced by:.
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On or before the due date, the Licencee shall send proof to the LPA that the emergency drills have been conducted on a quarterly basis over the past year and if those records are not available, then proof that 1 drill for every shift has been conducted at the facility and a schedule for the other drills during 2025.
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Based on record review, the Licensee did not comply with the section cited above. A record of the drills was not readily available to licensing agency staff, 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: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

1 Type-A and 3 Type-B deficiencies cited and 2 Civil Penalties for Repeat Violations for $250 each were issued during the visit.

Deficiencies and plan and proof of corrections were discussed with the Licensee. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809-D. Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights, LIC 9098 Proof of Correction form, and copy of this report were provided.
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
LIC809 (FAS) - (06/04)
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