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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881513
Report Date: 06/27/2024
Date Signed: 06/27/2024 02:53:49 PM

Document Has Been Signed on 06/27/2024 02:53 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SOUL AND HEARTS LLCFACILITY NUMBER:
371881513
ADMINISTRATOR/
DIRECTOR:		POWELL, DUSHAWNFACILITY TYPE:
735
ADDRESS:1427 PHILIPS STREETTELEPHONE:
(858) 977-9999
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY: 4CENSUS: 0DATE:
06/27/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:DuShawn Powel, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an announced Pre-licensing visit at Soul and Hearts LLC for licensure. The LPA was greeted and granted entrance into the home by Licensee Ravneet Pahwa. Administrator DuShawn Powell arrived shortly.

Application: The application is for an Adult Residential Facility. The fire clearance has been granted for four (4) ambulatory clients.

Buildings and Grounds: The home is a three (3) bedroom, two (2) bathroom one story home. LPA observed a living room, kitchen and dining area, laundry room, garage and a backyard area. Of the three bedrooms, one are shared two residents to a room and two bedrooms are private one resident to a room. The exterior pathways of the home were observed to be clutter free with no obstructions present. There are no pools or other bodies of water located at the home. Interior passageways were clear and free of obstruction. The bedrooms are completely furnished with a bed, night stand, dresser, chair, adequate lighting and privacy is available. Night light was observed in the hallway near the bedrooms. According to Licensee, there are no weapons stored in the home. Rooms, furniture , beds, mattresses are all in good repair. The dining and living room areas are clutter free and appropriately furnished. The hot water temperature was tested and measured at 108 degrees Fahrenheit, which was within regulatory limits. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer are available and in working order. Smoke and Carbon Monoxide detectors were tested and operable. The phone number designated for the facility is (760) 295-2159. The fire inspection was conducted and approved on 3/4/2024. The emergency exits are free of obstruction.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SOUL AND HEARTS LLC
FACILITY NUMBER: 371881513
VISIT DATE: 06/27/2024
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Storage and Supplies: Medications will be stored inaccessible to any unauthorized individuals. Secured areas are available for facility files and client files. The First Aid kits were observed to be available and complete. Cleaning supplies will be stored away in the garage along with linens, and personal hygiene supplies. Bathrooms were observed to have grab bars in the shower, non-slip bath mats, and closed-lid waste baskets. Three fire extinguishers were available and fully charged.

Food Service: The kitchen was observed to have dishes, silverware, pots, and pans. Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps are stored in a secured kitchen cabinet, available only to authorized individuals.

Forms: The following forms were observed to be posted at the home: Emergency Disaster Plan (LIC 610D), Personal Rights, and Facility Sketch (LIC 999), as well as other signage throughout the facility.

The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure. This report was discussed with and a copy provided to Administrator DuShawn Powell.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
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