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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201145
Report Date: 09/19/2023
Date Signed: 09/19/2023 03:18:27 PM

Document Has Been Signed on 09/19/2023 03:18 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HEARTWOOD VILLASFACILITY NUMBER:
079201145
ADMINISTRATOR:ARNANTE, CLAUDIOFACILITY TYPE:
735
ADDRESS:1561 HEARTWOOD DRIVETELEPHONE:
(925) 687-1230
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 4CENSUS: 4DATE:
09/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Eufemia Santos, CaregiverTIME COMPLETED:
03:30 PM
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On 09/19/2023 at 1:30 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival LPA was greeted by Caregiver, Eufemia Santos. LPA spoke to the Administrator, Claudio Arnante, on the phone and explained the purpose of the visit. Administrator was unable to join visit due to being on vacation with residents, Administrator allowed Eufemia to sign the report. The facility’s fire clearance was approved for 4 Ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 4 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 108.7 degree Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. The supply of extra hygiene’s were available for clients. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/08/2023. Emergency Disaster Drill was last posted on 06/24/2023. First aid kit was observed to be complete. Fire drill was last conducted on 07/29/2023 .

Report continues on 809 C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HEARTWOOD VILLAS
FACILITY NUMBER: 079201145
VISIT DATE: 09/19/2023
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At 2:00 PM, LPA reviewed 4 of 4 residents records. At 2:25 PM, LPA reviewed 4 of 12 staff records and 4 of 4 have current first aid training and associated to the facility.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/10/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 D Emergency Disaster Plan




No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC809 (FAS) - (06/04)
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