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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 05:58:30 PM

Document Has Been Signed on 05/21/2025 05:58 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Alanna Spencer/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit in response to the 3 Unusual Incident Reports submitted by the facility and received by LPA in April 2025 for resident (R1). UIRs indicated that on April 13, 2025, local police department informed the staff that resident (R1) was taken in custody and the details surrounding the incident remains confidential. Staff contacted the police department and was informed that R1 was released the same day. R1 did not return to the facility and staff filed a missing person report. The UIRs indicated that R1 was taken into custody again on April 15, 2025.

On this day, May 21, 2025, LPA met with staff Sameer Aziz and Elisa Chente. LPA later met with Alanna Spencer. LPA conducted interviews and obtained copy of R1's LIC602 Physician's Report and facility notes. LIC602 showed R1 can leave the facility unassisted. LPA also learned that on April 22, 2025, R1 was taken into custody again; however, no UIR submitted nor received by LPA.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. A $250.00 civil penalty is assessed for deficiency section # 80061(b)(E) for repeat violation within 12 month period. Failure to submit proof of correction (POC) by plan of correction due date may result in additional civil penalty.

Deficiency and plan and proof of correction were discussed with ADM. .

Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, 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
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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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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Document Has Been Signed on 05/21/2025 05:58 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/21/2025 at 05:23 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2025
Section Cited
CCR
80061(b)(E)

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80061 Reporting Requirements
(b)... In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.(E) Any unusual incident or client absence which threatens the physical or
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Administrator to do the following and submit proof by 6/04/25:
1. Read the Regulations and submit self-certification it will be followed.
2. Submit the incident report.

A $250.00 civil penalty is assesed.
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 emotional health or safety of any client.
-This requirement is not met as evidenced by:
-Based on interviews, the licensee did not comply with the section above in not submitting incident report for 4/22/25 which poses a potential safety risk to person in care.
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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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