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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201369
Report Date: 07/03/2024
Date Signed: 07/03/2024 12:48:08 PM

Document Has Been Signed on 07/03/2024 12:48 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:HOSPITABLE HEARTSFACILITY NUMBER:
019201369
ADMINISTRATOR/
DIRECTOR:		HALL, BRITTNEY EDWARDSFACILITY TYPE:
735
ADDRESS:557 33RD STREET #2TELEPHONE:
(510) 313-3595
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 3CENSUS: 0DATE:
07/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Britney Edwards Hall/Applicant-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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At 10:50 a.m. on this day, July 3, 2024, Licensing Program Analyst (LPA) Delmundo conducted an announced pre-licensing inspection, and met with Britney Edwards Hall, applicant-administrator. License application is for 3 total capacity, all ambulatory only. Fire clearance was granted on April 3, 2024.

Applicant submitted the LIC9282 Infection Control Plan and LIC610D Emergency Disaster Plan to Central Application Bureau (CAB) analyst.

LPA toured the facility inside out with applicant-administrator. LPA inspected the family room, kitchen, dining area, bedrooms, bathrooms, side and backyard. Bedrooms were observed appropriately furnished with adequate lighting and drawers. The facility has sufficient towels and linens. Supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed adequate for residents' use. There’s 7 days supplies of non-perishables and 2 days of perishables. Facility is equipped with refrigerator, microwave, dishwasher, washer and dryer. Kitchen cabinet under the sink where cleaning and laundry supplies were kept was observed locked. Central storage for medications and sharps was observed with lock. Common bathroom and ensuite bathroom were observed with non-skid mats. Passage way, hallways and deck in the backyard were free of hazards and obstructions. Deck and backyard were observed equipped with tables, chairs and shade.

Fire extinguisher was observed fully charge and according to applicant, it was purchased before facility was fire inspected. First aid kit inspected, and observed complete with manual. The 2 in 1 carbon monoxide and smoke detectors were tested and observed functional.

On this same day, LPA tested the facility telephone and observed working. LPA obtained a signed letter from the applicant stating a request to update the facility telephone number.

............continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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
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: HOSPITABLE HEARTS
FACILITY NUMBER: 019201369
VISIT DATE: 07/03/2024
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LPA observed the following:
-at 11:00 a.m., trash cans in the bedrooms and bathrooms without lids.
-at 11:12 a.m., side fence gate with hinged lock.
-at 11:19 a.m., hot water temperature at 122.6 degrees Fahrenheit.

Plan and proof of corrections (POCs) were discussed with the applicant. POCs to be submitted by July 17, 2024.

Upon receipt of POCs, LPA will inform CAB. Final review of application and license to be granted by CAB analyst.

Applicant to notify Oakland Office when first client is admitted to the facility and submit updated copies of the following:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan
4. LIC9282 infection Control Plan

Exit interview conducted, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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