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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200476
Report Date: 08/07/2025
Date Signed: 08/07/2025 04:48:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/28/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250528121744
FACILITY NAME:HEART AND SOUL COMMUNITIES IIFACILITY NUMBER:
019200476
ADMINISTRATOR:TILLIS, ERICKAFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 927-8046
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:6CENSUS: 8DATE:
08/07/2025
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Ericka Tillis, Licensee/AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee serves residents expired food
Licensee does not report incidents to appropriate parties
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/7/2025 at 2:10PM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegations above. LPA met with Licensee/Administrator, Ericka Tillis and explained the purpose of the visit.

During the course of investigation, LPAs interviewed 6 residents, 4 staff, and witness. LPAs obtained and reviewed documents including police report, medical records for R1, and physician's report for R2.

Licensee serves residents expired food
There was large amounts of expired foods observed on licensing visits dated 5/29/2025 and 6/19/2025.

(Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
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 5
Control Number 15-AS-20250528121744
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/07/2025
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
Licensee does not report incidents to appropriate parties
LPA G. Luk reviewed facility file and observed no incident reports were submitted when R1 went the hospital or when R2 had injuries.


Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250528121744
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2025
Section Cited
CCR
87555(b)(8)
1
2
3
4
5
6
7
General Food Service Requirements. All food shall be of good quality... This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee threw away the expired food and purchased additional non-perishable food supplies.
8
9
10
11
12
13
14
Based on observation, licensee did not comply with the section cited above by having expired non-perishable foods which poses a potential health and safety risk to the persons in care.
8
9
10
11
12
13
14
Deficiency cleared.
Type B
08/15/2025
Section Cited
CCR
87211(a)(1)
1
2
3
4
5
6
7
Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee has agreed to review reporting requirement and submit self-certification to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation, licensee did not comply with the section cited above by not submitting incident reports which poses a potential health and safety risk to the 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/28/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250528121744

FACILITY NAME:HEART AND SOUL COMMUNITIES IIFACILITY NUMBER:
019200476
ADMINISTRATOR:TILLIS, ERICKAFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 927-8046
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:6CENSUS: 8DATE:
08/07/2025
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Ericka Tillis, Licensee/AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable death
Licensee physically abuses resident
Licensee does not assist resident's with obtaining medical care
Licensee did not assist resident with obtaining prescribed medication
Licensee does not maintain facility sanitary
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/7/2025 at 2:10PM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegations above. LPA met with Licensee/Administrator, Ericka Tillis and explained the purpose of the visit.

During the course of investigation, LPA interviewed 6 residents, 4 staff and witness. LPA obtained and reviewed documents including police report, medical records for R1, and physician's report for R2.

Questionable death
R1’s medical records revealed that R1 was admitted to the hospital on 1/21/2025 and diagnosed with aspiration pneumonia and dysphagia. R1 was transitioned to comfort care and did not return to the facility. R1 was admitted to Skill Nursing Facility (SNF) on 1/25/2025 and passed away at the SNF on 2/3/2025.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250528121744
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/07/2025
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
Licensee physically abuses resident
Police report stated R2 had bruising on the left side of the face; however, R2 consistently stated R2 was not assaulted and could not stay on topic due to dementia diagnosis. Deputies were informed by S1 that the closet door fell on R2’s head when R2 rummaged through the closet and the closet door broke. Interview with residents revealed they have not witnessed staff physically abuse residents. Interview with staff indicated they have not heard or witnessed physical abuse towards residents.


Licensee does not assist resident's with obtaining medical care
Interview with staff indicated that R2's bump or bruise was observed. However, S1 stated that medical attention was not needed for R2's injury at that time and R2 did not complain of pain. S1 also stated that R2 was evaluated after injury was observed and injury site was flat.

Licensee did not assist resident with obtaining prescribed medication
Interview with staff revealed that S1 handle’s residents’ medications including ordering and picking up prescription medications. Facility did not keep medication records; therefore, LPA was unable to determine if resident’s prescription medications were obtained and administered.


Licensee does not maintain facility sanitary
Interview with residents revealed that staff clean the facility daily. Interview with staff indicated that staff cleans every morning. LPAs observed facility has cleaning supplies available.


Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5