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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005919
Report Date: 05/19/2022
Date Signed: 05/19/2022 03:51:13 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/19/2022 03:51 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:HEART TO HEART HOME CAREFACILITY NUMBER:
347005919
ADMINISTRATOR:FLORUTA, SERGIUFACILITY TYPE:
740
ADDRESS:5543 WILLOW OAK WAYTELEPHONE:
(916) 844-7741
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
05/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Lidia FlorutaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 5/1922 to conduct a Required-1 Year Inspection. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and licensees followed the infection control domain guidelines and facility was found to be in substantial compliance at this time.

LPA advised: Recording of daily staff and resident symptom screening, record of weekly testing of staff not fully vaccinated, fit testing for N-95s. LPA also advised that food be better organized to ensure monitoring of expiration dates

Licensee will submit copy of liability insurance certificate when renewed, LIC 308 for Designation of Responsible persons.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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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