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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200476
Report Date: 12/01/2021
Date Signed: 12/01/2021 02:28:21 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20201002115652
FACILITY NAME:HEART AND SOUL COMMUNITIES IIFACILITY NUMBER:
019200476
ADMINISTRATOR:GEORGE ANDRE SMITHFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 927-8046
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:6CENSUS: 6DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ericka Tillis, AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has around 9-10 residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/30/2021 at 1:15PM, Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to deliver complaint findings for the allegation above. LPAs met with Administrator/Licensee, Ericka Tillis.

The Department cited for the above allegation on the annual inspection visit dated 9/22/2021. LPAs L. Francisco and L. Hall observed 9 residents at the facility.

Based on LPAs observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), has been cited on the LIC9099D.

Exit interview conducted and a copy of this report provided.





Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20201002115652

FACILITY NAME:HEART AND SOUL COMMUNITIES IIFACILITY NUMBER:
019200476
ADMINISTRATOR:GEORGE ANDRE SMITHFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 927-8046
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:6CENSUS: 6DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Ericka Tillis, AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
More than 2 residents sleep in one room

Facility does not have staff on the premises at night
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/30/2021 at 1:15PM, Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Administrator/Licensee, Ericka Tillis.

During the course of the investigation, LPA J. Hamilton interviewed staff via tele-visit with residents present. LPA L. Hall interviewed S1. S1 stated facility has seven (7) rooms and at the time when the facility was over capacity 2 residents slept in each room.

On the allegation facility does not have staff on the premises at night. Record review, observation, and interview indicates that S1 lives at facility. Therefore, there is always staff on the premises at night.

Continued on LIC9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20201002115652
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HEART AND SOUL COMMUNITIES II
FACILITY NUMBER: 019200476
VISIT DATE: 12/01/2021
NARRATIVE
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3
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5
6
7
8
9
10
11
12
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15
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23
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25
26
27
28
29
30
31
32
Continued from LIC9099.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3