019200476-9-24-2024-15-AS-DDOE-D9F2SM-20240924173923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 09/24/2024
Date Signed: 09/24/2024 05:41:04 PM

Document Has Been Signed on 09/24/2024 05:41 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 II		FACILITY NUMBER:	019200476
ADMINISTRATOR:	GEORGE ANDRE SMITH		FACILITY TYPE:	740
ADDRESS:	2245 SOL STREET		TELEPHONE:	(510) 927-8046
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94578
CAPACITY:	6	CENSUS: 9	DATE:	09/24/2024
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Ericka Tillis, Administrator/Licensee		TIME COMPLETED:	06:00 PM

NARRATIVE

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On 9/24/2024 at 10:00 AM, Licensing Program Analysts (LPAs) David Doidge and James Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Ericka Tillis, Administrator/Licensee..

LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor areas. Centrally stored medications were locked in medication room. Smoke detectors and carbon monoxide detectors were observed and in working condition. Fire extinguishers were observed to be full and last serviced on 10/30/2024. Temperature in the facility was measured at 82. degrees Fahrenheit at 4:00 PM. Water temperature is 148 degrees Fahrenheit at 11:11 AM.

An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations.

Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished.

Indoor and outdoor passages were free of obstruction.

One week of nonperishable and 2 days of perishable food supplies were available.

3 A- and 2 B-type citations issued.

Continued on LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2024

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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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: 09/24/2024

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 LIC 809 Administrator will provide the following documents by 10/1/2024: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2024 05:41 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as water temperature was 147.3 degrees, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2024
	Plan of Correction
1 2 3 4	Reduce tempurature and send proof to LPA Sampair that water tempurature has been reduced to 105 to 120 range.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as Raid and other cleaning solutions were found in unlocked pantry kitchen and bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2024
	Plan of Correction
1 2 3 4	Cleared during visit

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: Bennett Fong	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2024 05:41 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(b)

Storage Space

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as medications found in unlocked storage in kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2024
	Plan of Correction
1 2 3 4	Cleared during inspectionn

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bennett Fong	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2024 05:41 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(f)(3)

Maintenance and Operation

(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as there were no lids found on trashbins which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	replace trash bins those that have lids and send proof to LPA Sampair.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bennett Fong	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/24/2024 05:41 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468(c)(2)(A)

Personal Rights of Residents

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as Complaint Poster, Personal Rights posters, and the Theft and Loss Policy were not posted. which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/01/2024
	Plan of Correction
1 2 3 4	Post required posters and send proof to LPA Sampair

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: Bennett Fong	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David Doidge	TELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC809 (FAS) - (06/04)

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