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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201105
Report Date: 11/16/2021
Date Signed: 11/16/2021 02:22:51 PM

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:CARING HEARTS ELDERLY HOMEFACILITY NUMBER:
079201105
ADMINISTRATOR:SANTOS VAHID, ELVIRAFACILITY TYPE:
740
ADDRESS:3498 SWALLOW COURTTELEPHONE:
(925) 948-5221
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 0DATE:
11/16/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Elvira Vahid, ApplicantTIME COMPLETED:
02:30 PM
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While at the facility for another reason, a Component III presentation was also completed during the Pre-licensing inspection with applicant/administrator. Common deficiencies at residential elderly care homes and Title 22 regulations were discussed with applicant who agreed to comply with all regulations and COVID-19 infection protocols.

The applicant was reminded of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification may be done by phone, by mail, or by fax.

This report was discussed with applicant and a copy was provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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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