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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201069
Report Date: 05/21/2025
Date Signed: 05/21/2025 05:56:06 PM

Document Has Been Signed on 05/21/2025 05:56 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:GENTLE HEART CARE SERVICES INCFACILITY NUMBER:
019201069
ADMINISTRATOR/
DIRECTOR:		SPENCER, ALANNAFACILITY TYPE:
735
ADDRESS:1559 D STREETTELEPHONE:
(510) 397-4813
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 4DATE:
05/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Alanna Spencer/AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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At 12:40 pm, on this day, May 21, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Sameer Aziz and Elisa Chente, and informed the reason for visit. LPA called and spoke with Alanna Spencer, administrator (ADM). ADM authorized Sameer Aziz to be with LPA during inspection. Administrator arrived at around 1:20 pm.

LPA inspected the facility inside and out including but not limited to living room, dining area. kitchen, laundry area, bedrooms, bathroom, front, side and backyard. Facility has supplies of 2 days of perishables and 7 days of non-perishable food. Fire extinguishers were observed fully charge with tags showed serviced April 16, 2025. Smoke and carbon monoxide detectors were tested and observed in operating condition. Hot water temperature in the common bathroom was tested at 120 degrees Fahrenheit. Storage for medications and sharps were observed locked. Facility conducts disaster drills monthly and records showed last conducted April 29, 2025.

LPA reviewed 4 residents and 5 staff files. Medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility handles residents' P&I which LPA checked and compared with last recorded balance.

LPA observed the following:
-at 12:40 pm, missing fence wood slab and gate and overgrown weeds about 2 feet to 4 feet high in the front, side and backyard.
-at 12:55 pm, rotten strawberries and grape tomatoes in the refrigerator.
..continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069
VISIT DATE: 05/21/2025
NARRATIVE
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-at 1:00 pm, unlocked cabinet where laundry and cleaning supplies are kept.
-at 1:05 pm, missing transition strip in between the hallway and kitchen and missing small piece of wood on the flooring in the hallway.
-at 1:06 pm, mildew in the shower door, walls and tub, stained wall, dusty/dirty baseboards and cabinets/drawers in the bathroom.
-at 1:13 pm, ceiling fans in the residents' room and living room dusty.

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

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $250.00 civil penalty is assessed for deficiency section # 80087(a) for repeat violation within 12 month period. Failure to submit proof of corrections (POCs) by plan of correction due date may result in additional civil penalties.

Deficiencies and plan and proof of corrections were discussed with ADM. .

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty, LIC9098 Proof of Correction form, and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/21/2025 05:56 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/21/2025 at 04:24 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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
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Based on observation, the licensee did not comply with the section cited above in unlocked cabinet where laundry and cleaning supplies are kept which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Staff locked the cabinet while LPA was at the facility.
In addition, administrator to in-service the staff and submit proof by 5/22/25.
Type A
Section Cited
CCR
80076(a)(1)
80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in rotten strawberries and grape tomatoes which pose an immediate health and/or personal rights risks to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Staff threw away the items while LPA was at the facility.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signature by 5/22/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/21/2025 05:56 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/21/2025 at 04:24 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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: missing fence wood slab and gate and overgrown weeds about 2 feet to 4 feet high in the front, side and backyard; missing transition strip in between the hallway and kitchen and missing small piece of wood in the flooring in the hallway; ceiling fans in the residents' room and living room dusty
POC Due Date: 06/04/2025
Plan of Correction
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Administrator to do the following and submit pictures by 6/04/25:
(1) Have the fence repaired/fixed; (1) Have the yard cleaned; (3) Install transition strip and repair the flooring; (4) Have the ceiling fans cleaned.
A $250.00 civil penalty is assessed for repeat violation within 12 month period.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the following which pose which pose a potential health, safety or personal rights risks to persons in care: mildew in the shower door, walls and tub; stained bathroom wall; dusty/dirty baseboards and cabinets/drawers in the bathroom
POC Due Date: 06/04/2025
Plan of Correction
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Administrator to have the bathroom cleaned and submit pictures by 6/04/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2025


LIC809 (FAS) - (06/04)
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