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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201259
Report Date: 03/06/2025
Date Signed: 03/06/2025 04:28:44 PM

Document Has Been Signed on 03/06/2025 04:28 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: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: 6DATE:
03/06/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Thinn AyeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On this day, LPA Luisa Fontanilla arrived at the facility to conduct case management inspection in connection with pre licensing due to change of ownership (CHOW).

LPA inspected the facility inside and out including but not limited to rooms, bathrooms, kitchen, dining area and backyard.

The following deficiencies were observed and corrected during the visit:
  • staff 1 (S1) is not fingerprint cleared - S1 was removed during the visit
  • hot water measured at 131 Fahrenheit - Hot water measured at 119


The following need to be corrected and submit proof of correction to CCL:
  • Insulin was observed unlocked in the refrigerator
  • One resident is diabetic and on insulin but unable to manage

Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D) and civil penalty of $500 is assessed for today's visit.

Exit interview was conducted with Thinn Aye and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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 03/06/2025 04:28 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/06/2025 at 01:30 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: HEAVENLY CARE HOME
FACILITY NUMBER: 019201259

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2025
Section Cited
CCR
87411(g)(1)

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87411 Personnel Requirements - General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:

(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations
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S1 was replaced by staff 2 (S2) and will be off schedule until cleared. Licensee will notify LPA once S1 is cleared.
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This requirement is not met as evidenced by: S1 is not fingerprint cleared but has been working at the facility.
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Type A
03/06/2025
Section Cited
CCR87303(3)(2)

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87303 Maintenance and Ope
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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Hot water was adjusted to 119 during the visit.
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This requirement is not met as evidenced by: Hot water measured at 131 Fahrenheit which poses an immediate risk to safety of residents.
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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