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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200540
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:17:06 PM

Document Has Been Signed on 02/14/2024 03:17 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: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: 2DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sharondalyn Conner/Administrator TIME COMPLETED:
03:20 PM
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At 12:00 noon on this day, February 14, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Sharondalyn Conner, administrator, and informed the reason for visit.

Administrator submitted the facility's Infection Control Plan which the Department received on February 13, 2023.

LPA inspected the living room, dining area, kitchen, bedrooms, bathroom, front and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and storage for cleaning supplies were observed locked.

Facility has carbon monoxide and smoke detectors that were observed functional. Facility conducts fire and emergency/disaster drills every month, and records showed last conducted 2/11/24 and 2/07/24 respectively. Fire extinguisher checked, observed fully charge with tag showed serviced 10/02/23. Hot water temperature in the bathroom was tested and measured at 119.4 degrees Fahrenheit.

LPA received copies of the following current/updated documents:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage.

...continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NOBLE HEARTS CARE HOME
FACILITY NUMBER: 019200540
VISIT DATE: 02/14/2024
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LPA reviewed 4 staff and 2 resident records, and interviewed 1 staff and 1 resident. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record. P&Is were checked and compared with the last recorded balance.

No deficiency observed during today's visit.

Exit interview conducted, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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