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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200540
Report Date: 02/23/2022
Date Signed: 02/23/2022 09:17:53 AM

Document Has Been Signed on 02/23/2022 09:17 AM - 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:NOBLE HEARTS CARE HOMEFACILITY NUMBER:
019200540
ADMINISTRATOR:SHARONDALYN CONNERFACILITY TYPE:
735
ADDRESS:846 37TH STREETTELEPHONE:
(510) 250-9410
CITY:OAKLANDSTATE: CAZIP CODE:
94608
CAPACITY: 5CENSUS: 0DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:55 AM
MET WITH:Not AvailableTIME COMPLETED:
09:20 AM
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 2/23/22 at 7:55 a.m., Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced Infection Control Inspection.

LPA saw that a note of "Noble Hearts Care Home staff and residents go to field trip on 2/23/22" was posted on the front window. LPA knocked the door many times and tried to look inside through windows, however, all windows were covered by the blinds. LPA didn't hear any sounds inside facility. LPA called Administrator and left voice message. LPA walked to the backyard of facility, and observed a piece of wood in the middle of stairway up to facility was broken, painting on stairs was peeling off. 2 water heaters in the backyard were exposed because their covers were fell off and laid on the floor. LPA observed that "Caution" yellow tapes had been used and some of them were still hung on both sides of stair handles.

Since this is an attempted visit, LPA will return to facility for inspection again.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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 1