<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 01/29/2025
Date Signed: 01/31/2025 12:43:35 PM

Document Has Been Signed on 01/31/2025 12:43 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
CCLD Regional Office, 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:
01/29/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Ericka Tillis, Licensee TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, January 29, 2025 at 10:40 am, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and J. Sampair arrived unannounced to conduct case management inspection as part of monitoring plan from Non-compliance Conference held on November 07, 2024. LPA met with Licensee Erika Tillis, and informed the reason for visit.

LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms. LPA inspected the food supples and observed good for 2 days of perishables and 7 days of non-perishables. During the health and safety check, LPA observed a total of 3 staff members and 9 residents at the facility.

The following deficiencies are observed:

Annuals fees are outstanding for 2019, 2020, 2021, 2022, 2023 and 2024.


Late fees have been assessed and are outstanding for 2019, 2021, 2022, 2023 and 2024.
S1 does not have a valid Administrator Certificate
S3 is not fingerprint cleared and associated to the facility
Facility is caring for residents who are non-ambulatory
Facility is caring for residents beyond the conditions and limitations specified on the license
Facility is licensed for only ambulatory residents, but is caring for residents who are diagnosed with dementia

Continued on 809-C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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 6
Document Has Been Signed on 01/31/2025 12:43 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/29/2025 at 12:18 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
Section Cited
CCR
87406(a)

1
2
3
4
5
6
7
All individuals subject to criminal record review shall be fingerprinted... Criminal Record Statement... (3) The licensee shall submit these fingerprints... for the purpose of searching the records... prior to the individual's employment, residence, or initial presence in the facility.
1
2
3
4
5
6
7
Administrator agreed to get S3 fingerprinted and submit proof to CCLD by POC date.

A $500.00 civil penalty is assessed.
8
9
10
11
12
13
14
Based on record review the Licensee did not comply with the section cited above in having S3 fingerprinted before working at facility which poses a potential immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Request Denied: Appeal Not Submitted Timely
Type A
01/31/2025
Section Cited
CCR87355(d)

1
2
3
4
5
6
7
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
By POC date Administrator agrees to submit documents for certificate renewal and notify CCLD
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above in not having a valid administrators certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/31/2025 12:43 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/29/2025 at 03:16 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
01/31/2025
Section Cited
CCR
87204(b)

1
2
3
4
5
6
7
Limitations - Capacity and Ambulatory Status (b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms
1
2
3
4
5
6
7
On or before the due date, a plan of relocation for the non ambulatory residents will be submitted to CCLD.
8
9
10
11
12
13
14
 a review of the records revealed that the facility licensed for all ambulatory residents, but 5 of 6 residents currently living in the facility are nonambulatory, which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Request Denied: Appeal Not Submitted Timely
Type A
01/31/2025
Section Cited
CCR87705(c)(1)

1
2
3
4
5
6
7
Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills.
1
2
3
4
5
6
7
On or before the due date, the nonambulatory residents will leave facility.
8
9
10
11
12
13
14
a review of the records revealed that 4 of 6 residents are diagnosed with dementia, but the facility is licensed for only ambulatory residents, which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/31/2025 12:43 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/29/2025 at 03:22 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
01/31/2025
Section Cited
CCR
87204(a)

1
2
3
4
5
6
7
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…
1
2
3
4
5
6
7
On or before the due date, the addtional residents will leave facility.
8
9
10
11
12
13
14
Based on observations LPA's observed 9 residents at the care facility being cared for.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/29/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
...Continued from 809

Deficiencies are cited from Title 22 California Code of Regulations (see 809D's). A $500.00 civil penalty is assessed for deficiency #87355(d). A $750 immediate civil penalty assessed for repeat citations 87204(b), 87705(c)(1) and 87204(a). Failure to submit proof of correction along with the LIC9098 Proof of Correction by due date may result in additional civil penalty.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/31/2025 12:43 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 01/29/2025 at 11:27 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
01/31/2025
Section Cited
HSC
1569.185(a)(1)

1
2
3
4
5
6
7
(a)(1) An application fee adjusted by facility and capacity shall be charged by... After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license.
1
2
3
4
5
6
7
Licensee to make payment and provide proof of that payment to CCL by the POC date.

Outstanding Annual Fees: $2970.00
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
LPA conducted a records check via LIS which revealed outstanding annual fees due to the department which poses a potential risk to the health and safety of residents in care.
8
9
10
11
12
13
14
Request Denied: Appeal Not Submitted Timely
Type A
01/31/2025
Section Cited
HSC1569(b)(1)(f)

1
2
3
4
5
6
7
(b) (1)...fees set forth in subdivision (a), the department shall charge all of the following fees: (F) A late fee that represents an additional 50 percent of the established current annual fee when a licensee fails to pay the current annual licensing fee on or before the due date as indicated by postmark on the payment.
1
2
3
4
5
6
7
Licensee to make payment and provide proof of that payment to CCL by the POC date.

Outstanding Annual Fees: $1,482.00
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
LPA conducted a records check via LIS which revealed outstanding late fees due to the department which poses a potential risk to the health and safety of residents in care.
8
9
10
11
12
13
14
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: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
Page: 6 of 6