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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201069
Report Date: 05/09/2023
Date Signed: 05/09/2023 06:50:04 PM

Document Has Been Signed on 05/09/2023 06:50 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:SPENCER, ALANNAFACILITY TYPE:
735
ADDRESS:1559 D STREETTELEPHONE:
(510) 397-4813
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 5DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Staff, Sameer Aziz
and Rosa Ramirez		TIME COMPLETED:
06:30 PM
NARRATIVE
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On this day, May 9, 2023, at 12:10 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Sameer Aziz and
Rosa Ramirez. and informed the reason for visit. LPA spoke with Alanna Spencer, administrator, who can not come to the facility, and authorized Sameer Aziz to be with LPA during inspection, and sign and receive this report.

Facility has an approved LIC808 Mitigation Plan and an LIC9282 Infection Control Plan on file.

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 sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced March 20, 2023. Facility has smoke detector that was observed operational. Hot water temperature in the common bathroom was tested.

LPA reviewed 5 residents and 5 staff files, and interviewed 2 residents and 2 staff. Medications were checked and compared with records. Storage for medications and sharps were observed locked. First aid kit inspected and observed complete with manual.

LPA observed the following:
-at 12:30 pm, broken door bell
-at 12:44 pm, Purell Professional disinfectant and broken toilet paper holder in the bathroom
-at 12:49 pm, hot water temperature at 138.5 degrees Fahrenheit
-at 12:54 pm, Centrum for Women in one of male resident's room; ripped window blinds; broken drawer

..continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069
VISIT DATE: 05/09/2023
NARRATIVE
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-at 12:56 pm, ripped window blind in the laundry area
-at 1:01 pm, over grown weeds about 1 to 1 1/2 feet tall and missing fence door plank in the front yard
-at 1:02 pm, broken chair, crutches. soiled metal grill, bathing chair in the side yard
-at 1:05 pm, backyard fence torn down
-at 4:15 pm, resident (R1) has 1 medication on facility's hand but no doctor's order on file. R1's LIC622 Centrally Stored Medication and Destruction Record is incomplete- medications filled on 5/03/23 not recorded.
-at 4:30 pm, resident (R2) has 1 medication with no doctor's order on file

LPA received on this day copies of the following updated/current documents:
1. LIC610D Emergency Disaster Plan (9 pages)
2. LIC9282 Infection Control Plan
3. Alanna Spencer's administrator certificate (# 6055329735)

Administrator to submit the following updated documents by May 23, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. Proof of Surety Bond coverage

Deficiencies are cited 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 penalties.

Deficiencies and plan and proof of corrections were discussed with Sameer Aziz.

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: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 05/09/2023 06:50 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/09/2023 at 05:22 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: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above for not having a carbon monoxide detector which poses an immediate safety risk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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2
3
4
Administrator to have a staff purchase and install the detector, and submit picture by 5/10/23.
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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2
3
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Based on observationm the licensee did not comply with the section cited above for having a Purell disinfectant in the bathroom readily accessible to residents which poses an immediate safety risk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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2
3
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Staff locked the item.
In addition, administrator to conduct an in-service training and submit copy of with attendees signatures by 5/10/23.
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: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/09/2023 06:50 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/09/2023 at 05:22 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: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(h)
Building and Grounds
(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above for the Centrum in one of resident's room which poses an immediate health and r personal rights risk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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2
3
4
Staff took and locked the item immediately.
In addition, administrator to conduct an in-service training and submit copy of with attendees signatures by 5/10/23.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 for hot water temperature at 138.5 degrees Fahrenheit in the resident's bathroom which poses an immediate safety tisk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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Administrator to have the water temperature adjusted within Regulations range and submit proof by 5/20/23.
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: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/09/2023 06:50 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/09/2023 at 05:22 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: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 2 out of 5 residents with medications withoiut doctor's order on file which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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Administrator to check with the residents' doctor if the medications are still needed, and obtain copy of doctor's orders. If medications are no longer needed, to obtain a discontinued order. Proof to be submitted by 5/10/23.

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: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/09/2023 06:50 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/09/2023 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: 05/09/2023

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above for the following: broken door bell; ripped window blinds; broken front & backyard fence; broken drawer; over grown weeds in the front yard; broken chair, crutches. soiled metal grill, bathing chair in the side yard - these pose a potential health, safetyand/ or personal rights risk to persons in care.
POC Due Date: 05/23/2023
Plan of Correction
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2
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Administrator to have the yards cleaned, replace the blinds, fix the front & backyard fences; repair or replace the door bell; repair or replace the drawer. Proof/pictures to be submitted by 5/23/23.
Type B
Section Cited
CCR
80061(b)
Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above for reporting to the Department the following day when resident (R2) AWOLed which posed a potential safety and personal rights risk to person in care.
POC Due Date: 05/23/2023
Plan of Correction
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Administrator to read the Regulaton and submit by 5/23/23 a self-certification it's understood. In addition, administrator to ensure timely reporting.
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: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 05/09/2023 06:50 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/09/2023 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: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above for not having the medications filled on 5/03/23 recorded on LIC622 which pose a potential health, and personal rights risk to persons in care.
POC Due Date: 05/23/2023
Plan of Correction
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2
3
4
Administrator to have LIC622 completed and submit copy by 5/23/23.
Type B
Section Cited
CCR
80023(d)
Other Provisions
80023 Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews and record review, the licensee did not comply with the section cited above for not conducting drills which poses a potential safety risk to persons in care.
POC Due Date: 05/23/2023
Plan of Correction
1
2
3
4
Administrator to have drills conducted and keep record. Copy to be submitted by 5/23/23.
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: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
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