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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201259
Report Date: 02/13/2025
Date Signed: 02/13/2025 11:49:05 AM

Document Has Been Signed on 02/13/2025 11:49 AM - 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:HEAVENLY CARE HOMEFACILITY NUMBER:
019201259
ADMINISTRATOR/
DIRECTOR:		NIRMALA KUPPUSAMYFACILITY TYPE:
740
ADDRESS:36857 WALNUT ST.TELEPHONE:
(925) 963-4081
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 5DATE:
02/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Thinn Aye, Licnesee TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 02/13/2025 at 09:00 AM while LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20241017160414) LPA observed the following deficiencies:
  • that current and past resident records are not stored separate and complete
  • Medications were left out and accessible to residents

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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 2
Document Has Been Signed on 02/13/2025 11:49 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 02/13/2025 at 10:16 AM
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: HEAVENLY CARE HOME
FACILITY NUMBER: 019201259

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2025
Section Cited
CCR
87465(h)(2)

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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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The Administrator will conduct in service training with topics including centrally stored medications to staff and proof of correction will be submitted CCLd by POC date.
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Based on observation, the licensee did not comply with the section cited above in not having medication locked which poses an immediate health and safety risk to persons in care.
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Type A
02/18/2025
Section Cited
CCR87506(a)

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The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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The Administrator will create separate and complete files for all residents in care and proof of correction will be submitted CCLd by POC date.
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Based on observation, interview, and record review the Licensee did not comply with the section cited above in having separate or complete records for the residents in care which poses an immediate health and safety risk to persons 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
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