286804084-8-3-2023-21-AS-CFOR-CUCT6E-20230803142702

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804084
Report Date: 08/03/2023
Date Signed: 08/03/2023 02:27:07 PM

Document Has Been Signed on 08/03/2023 02:27 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	HEART TO HEART PROVIDER, LLC		FACILITY NUMBER:	286804084
ADMINISTRATOR:	LALIM, LEONARDO		FACILITY TYPE:	740
ADDRESS:	3684 JOMAR DRIVE		TELEPHONE:	(707) 226-5684
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 6	DATE:	08/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Leonardo Lalim, Administrator		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA), C. Fowler is conducting an Required-1 Year inspection, on 08/03/23 at approximately 09:30am, and met with Administrator Leonardo Lalim. LPA observed one caregivers on duty during the inspection.

Currently six (6) residents in care. Facility has an approved fire clearance four (6) non-ambulatory residents. There are 2 shared rooms and 2 private rooms. The facility has required emergency disaster plan.

Facility had an evacuation fire drill on 07/02/23, including staff & residents. Residents, 1 out of 6, has a special diet regarding food and are followed per staff interviews, and per LPA's observations during the inspection.

The LPA reviewed two (2) staff files. Administrator certificate for Leonardo Lalim is current-#6062738740, expires 05/03/2024. All staff have required criminal record clearance. All staff have required training. The LPA reviewed four(4) resident files. Resident files were complete.

The LPA toured the facility with the Administrator. All exits were unobstructed. The facility fire extinguishers were serviced and tagged as required expires 09/27/2022. Facility had six(8) smoke alarms and carbon monoxide detectors which were working properly when checked during the inspection. Facility had a first aid kit stored in locked kitchen storage, it did have a required first aid booklet. The facility had a sufficient supply of perishable and nonperishable food.

Continue on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HEART TO HEART PROVIDER, LLC	FACILITY NUMBER: 286804084
	VISIT DATE: 08/03/2023

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The facility had food, water, and emergency supplies to meet the 72 hour shelter in place requirement. The facility had a sufficient supply of personal protective equipment(PPE) for use as needed. The facility had a sufficient supply of hygiene supplies, cleaning supplies, and paper products for use as needed. The LPA observed the facility to be clean and orderly during the visit. The LPA observed that resident rooms, common areas, hallways, and bathrooms had sufficient lighting for residents in care. Residents rooms had required accommodations per regulations. Facility had all medications locked up and inaccessible to residents in care as required. Facility had all cleaners/toxins locked up and inaccessible to residents in care as required.

LPA is requesting the following forms be updated and submitted to CCL by 8/11/23:

LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required)
Infection Control Plan-if any changes, as discussed
Copy of Current Liability Insurance
Copy of current Administrator Certificate

No deficiencies/citations during today's inspection. Exit interview conducted with the Administrator.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC809 (FAS) - (06/04)

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