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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201069
Report Date: 01/08/2025
Date Signed: 01/08/2025 04:06:49 PM

Document Has Been Signed on 01/08/2025 04:06 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: 6DATE:
01/08/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:25 PM
MET WITH:Alanna Spencer/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 8/22/24, Licensing Program Analyst (LPA) Delmundo called and spoke with Alanna Spencer, administrator (ADM) regarding the annual fees that were overdue and late fee assessment. ADM stated she'll pay Monday, 8/26/24; however, the fees remained unpaid.

On this day, 1/08/25, LPA arrived to the facility unannounced for a complaint (15-AS-20241230154440). LPA met with Alanna Spencer, administrator (ADM), and discussed the above. LPA also informed the ADM that LPA will issue citation for not submitting incident report when resident (R1) broke into the neighbor's property.

Deficiencies are from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections (POCs) by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with the ADM. ADM has to leave and authorized Sameer Aziz to sign and receive this report.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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 3
Document Has Been Signed on 01/08/2025 04:06 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/08/2025 at 03:33 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: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2025
Section Cited
CCR
80036(a)

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80036 LICENSING FEES
(a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1.

-This requirement is not met as evidenced by:
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Corrected.
Administrator paid the annual fees online while LPA was at the facility.
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-Based on record review and interview, the licensee did not comply with the section above for not paying the annual fees for 2022, 2023 and 2024 ($1362.00)
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Type B
01/22/2025
Section Cited
CCR80036(b)(1)(F)

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80036 Licensing Fees (b)(1) In addition to fees set forth in subdivision (a), the department shall charge the following fees:(F) A late fee that represents an additional 50 percent of the established current annual fee when any licensee fails to pay the current annual licensing fee on or before the due date
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Corrected.
Administrator paid the late fees online while LPA was at the facility.
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-This requirement is not met as evidenced by:
-Based on record review and interview, the licensee did not comply with the section above in not paying the late fees of $681.00
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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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/08/2025 04:06 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/08/2025 at 03:42 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: 01/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2025
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 1/22/25:
1. Read the Regulations and submit self-certification it will be followed.
2. Submit the incident report.
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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 when R1 broke into the neighbor's property 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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2025


LIC809 (FAS) - (06/04)
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