371881513-8-22-2025-18-AS-JGEE-DKSQWM-20250822123210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881513
Report Date: 08/22/2025
Date Signed: 08/22/2025 12:32:17 PM

Document Has Been Signed on 08/22/2025 12:32 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 LLC		FACILITY NUMBER:	371881513
ADMINISTRATOR/ DIRECTOR:	PAHWA, RAVANEET		FACILITY TYPE:	735
ADDRESS:	1427 PHILIPS STREET		TELEPHONE:	(858) 977-9999
CITY:	VISTA	STATE: CA	ZIP CODE:	92083
CAPACITY: 4		CENSUS: 2	DATE:	08/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:18 AM
MET WITH:	Barthelmey Delva, Direct Support Professional		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/22/25 Licensing Program Analyst (LPA) Javina George made an unannounced to the facility to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Direct Support Professional (DSP) Barthelemy Delva, where LPA explained the purpose of the visit. The administrator was unavailable to come to the facility as there are currently in a training. The facility is licensed to serve four (4) ambulatory clients. Below are the observations made during today's inspection: The facility was observed to be clean and free of any obstructions. The facility is a single story structure consisting of (3) bedrooms and (2) bathrooms, laundry room, office area, garage, den, dining area and backyard. All staff files reviewed were observed to be staff that have obtained criminal record clearance and to be associated to the facility. The files are electronic and staff present did not have access, therefore LPA was unable to review training received. Client files, did not have the required paperwork such as admissions agreement. The Personal and Incidental funds were not reviewed as the staff present did not have access. LPA provided a copy of LIC311C- Records to be maintained at the facility. The facility food supply was observed to be sufficient as there was a 2 day supply of perishable and a 7 day supply of non perishable food items. The facility was observed to utilize video surveillance in the common area as well as at the entrance of the facility. The facility sketch will be updated, as well as an addendum to the program statement and the clients will sign an acknowledgment stating that there are aware video surveillance is being utilized at the facility. Due to the department by 5pm on or before 08/28/25.

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 08/22/2025

NARRATIVE

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The fire extinguishers were last serviced 01/29/25, the combined smoke and carbon monoxide detectors were tested and found to be operable. The hot water was tested and was found to be within regulatory limits measuring at 113.4 degrees Fahrenheit. The medications, sharps and chemicals were observed to be locked and inaccessible to clients in care. The facility could not provide a record of emergency disaster drills that were conducted, deficiency cited.

The facility had emergency supplies such as food and water first aid kit and flashlights. LPA observed for there to be a lock on a cabinet inside the kitchen that did contain snacks that are high in sugar such candy, soda, apple sauce. Per the Administrator the cabinet is not locked, and was not originally being used to store food. However it was found to be locked during LPAs inspection. The items were removed during LPAs visit.

The facility was observed to have a valid surety bond as well as liability insurance. The governing body was observed to be in good standing. The facility annual fees were due on 08/06/25, LPA provided PIN # 572351, as the administrator stated the fees will be paid today.

Based on today's inspection a citation is being issued on the attached 809D, in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6)

An exit interview was conducted and a copy of this report, 809D, LIC811-Confidential names list, LIC9098-Proof of corrections form and appeal rights, were reviewed and provided to Barthelemy Delva, DSP.

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Javina George
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2025 12:32 PM - It Cannot Be Edited

Created By: Javina George On 08/22/2025 at 11:58 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SOUL AND HEARTS LLC	FACILITY NUMBER: 371881513
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/23/2025
	Plan of Correction
1 2 3 4	The licensee agrees to conduct an emergency disaster drill, and document it. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:

	Javina George
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

LIC809 (FAS) - (06/04)

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