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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601242
Report Date: 03/25/2024
Date Signed: 03/25/2024 10:17:08 AM


Document Has Been Signed on 03/25/2024 10:17 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:HEART & SOUL COMMUNITIESFACILITY NUMBER:
015601242
ADMINISTRATOR:TILLIS, ERICKAFACILITY TYPE:
740
ADDRESS:3770 SUTER STREETTELEPHONE:
(510) 927-8046
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:6CENSUS: 0DATE:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ericka Tillis, AdminstratorTIME COMPLETED:
10:45 AM
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On 3/1/24 at 10:30am LPA K.Nguyen arrived unannounced to conduct one year annual Inspection. LPA spoke with Administrator Ericka Tillis via phone. AD stated there are no resident, and LPA schedule for a time to come back.

On 3/5/24 at 9:15am LPA K.Nguyen arrived at the facility. Administrator Ericka Till called and reschedule with LPA stating that she had an emergency. LPA schedule for a time to come back.

On 3/25/2024 at 9:00 am Licensing Program Analyst (LPA) K. Nguyen arrived for a Health and Safety Check/ including an annual inspection. LPAs met with Ericka Tillis, Administrator.

During the visit LPAs observed that there are currently no resident residing at the facility. LPAs checked Carbon Monoxide detector, Smoke Detector, and Emergency Exits. Fire extinguisher was last serviced on 10/30/2023.


Exit interview conducted at 10:45am. A copy of this report provided to Administrator via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024
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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