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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201069
Report Date: 05/24/2024
Date Signed: 05/24/2024 05:53:42 PM

Document Has Been Signed on 05/24/2024 05:53 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: 5DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Elisa Chente/Staff and
Alanna Spencer/Administraror 		TIME VISIT/
INSPECTION COMPLETED:
05:55 PM
NARRATIVE
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.At 10:15 a.m. on this day, May 24, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Elisa Chente, and informed the reason for visit. LPA called and spoke with Alanna Spencer, administrator, and authorized Elisa Chente to be with LPA during inspection. Administrator arrived at around 11:38 a.m.

Facility has LIC9282 Infection Control Plan which was submitted on May 9, 2023.

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 8, 2024. Smoke and carbon monoxide detectors were tested and observed operational. Hot water temperature in the common bathroom was tested. Storage for medications and sharps were observed locked. First aid kit inspected and observed complete with manual. Fire drill records checked.

LPA reviewed 5 residents and 5 staff files, and interviewed 2 residents and 2 staff. 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 10:20 am, missing fence wood slabs and overgrown weeds about 2 feet to 5 feet high in the front yard.
-at 10:25 a.m., chipped wall and paint in between living room and dining area.
-at 10:30 a.m., trash can in the dining area without lid.
-at 10:41 a.m., shower area with mildew and trash can's lid not properly working.

..continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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: GENTLE HEART CARE SERVICES INC
FACILITY NUMBER: 019201069
VISIT DATE: 05/24/2024
NARRATIVE
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-at 10:45 a.m., hot water at 103 degrees Fahrenheit.
-at 10:50 a.m., pieces of wood in the side yard.
-at 11:20 a.m., fire drill not conducted quarterly. Records showed last conducted 10/15/23 and 3/04/24.
-at 12:45 p.m., staff (S3) has no LIC503 Health Screening Report and TB test on file.
-at 3:45 p.m., resident's (R2) Lithium Carbonate (300 mg) in facility's hand is 1 capsule in the morning and 3 capsules at bedtime. but doctor's order on file is 300 mg capsule at bedtime.

On April 25, 2024, administrator submitted an updated copy of the following:
1. LIC500 Personnel Report dated 4/01/24
2. Facility sketch showing the old garage/carport at the back of the facility converted into a parking area.

Administrator submitted on this day, 5/24/24, copies of the following updated/current documents:
1. LIC308 Designation of Facility Responsibility
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. 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 the administrator. Administrator has to leave and have Elisa Chante 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: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/24/2024 05:53 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/24/2024 at 04:57 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: 05/24/2024

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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2
3
4
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 risk to persons in care: mising fence wood slabs and overgrown weeds about 2 feet to 5 feet high in the front yard; chipped wall and paint in between living room and dining area; trash cans in the dining area without lid; shower area with mildew and trash can's lid not properly working; pieces of wood in the side yard.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator to do the following and submit proof by 6/07/24:
1. Have the yard and shower cleaned.
2. Purchase trash can with foot pedal operated lid.
3. Have the chipped wall repaired and repainted.
Type B
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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4
Based on observation, the licensee did not comply with the section cited above in hot water at 103 degrees Fahrenheit which poses a potential health and/or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator to have the water temperature adjusted and submit proof by 6/07/24.
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: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/24/2024 05:53 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/24/2024 at 04:57 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: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on record review, the licensee did not comply with the section cited above in S3 not having LIC503 Health Screening on file which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator to have the staff health screened and submit LIC503 by 6/07/24.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in S3 not having TB test on file which poses a potential health and/or personal rights risks to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator to have the staff TB tested and submit proof by 6/07/24.
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: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/24/2024 05:53 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/24/2024 at 04:57 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: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in not conducting drills every quarter which poses a potential saafety risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator to have the drills conducted as required and submit self-certification by 6/07/24,
Section Cited
Deficient Practice Statement
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2
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POC Due Date:
Plan of Correction
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4
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: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/24/2024 05:53 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/24/2024 at 05:12 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: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)
80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
(6)(D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in R2's current Lithium Carbonate medication with no current/uodated doctor's order on file which poses an immediate health and/or personal rights risks to persons in care.
POC Due Date: 05/25/2024
Plan of Correction
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Corrected.
Administrator obtained doctor's order while LPA was at the faciliity.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
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