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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200476
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:21:53 PM


Document Has Been Signed on 09/10/2024 02:21 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: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: 9DATE:
09/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ericka Tillis, Licnesee TIME COMPLETED:
02:30 PM
NARRATIVE
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While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20240514153218) on 09/10/2024, LPA observed the following:

Chemical cleaner left out in the bathroom
A rope that was tied a door closed in the residents living room


The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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


Document Has Been Signed on 09/10/2024 02:21 PM - It Cannot Be Edited

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: HEART AND SOUL COMMUNITIES II
FACILITY NUMBER: 019200476

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2024
Section Cited
CCR
87309(a)

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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement is not met as evidenced by…
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POC cleared during visit.
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405 chemical cleaner left out in upstairs bathroom.
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Type B
09/17/2024
Section Cited
CCR87705(l)(2)

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the licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement was not met as evidenced by
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POC cleared during visit.
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 a rope tying the door in the residents living room.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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