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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701647
Report Date: 07/10/2026
Date Signed: 07/28/2026 09:37:37 AM

Document Has Been Signed on 07/28/2026 09:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CARING HEARTS ELDER CAREFACILITY NUMBER:
392701647
ADMINISTRATOR/
DIRECTOR:		MATIN, GOLALAIFACILITY TYPE:
740
ADDRESS:2078 ASHLEY LANETELEPHONE:
(510) 575-4650
CITY:TRACYSTATE: CAZIP CODE:
95377
CAPACITY: 6CENSUS: 6DATE:
07/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Golalai MatinTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Unannounced Annual visit made out to this facility on 07/10/2026 by Licensing Program Analysts (LPAs) Charlie Yang and Kimberly Kulich who was met by the facility designated Administrator Golalai Matin who was briefly interviewed at this time.
Current census was 6 residents.
It was learned that there weren't any residents under the care of hospice at this time. It was learned that this facility does have an approved hospice waiver to be able to accept and retain up to 2 hospice residents at any given time.
It was learned that there were (3) residents deemed to have the diagnosis of dementia at this time. It was learned that this facility does have a dementia program on file at this time.
It was learned that there was (1) resident receiving services through home health at this time.
It was learned that there weren't any residents deemed to be bedridden at this time. This facility does have an approved bedridden fire clearance to be able to accept and retain up to (1) resident to occupy designated bedroom #1.
There were (2) other facility staff members, S1 and S2, present during this annual visit.
Tour of the facility was conducted.
A tour of the living area, dining area, and all other areas intended for resident use was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. Cabinets and drawers were reviewed at this time. Drawers storing knives and sharps were reviewed to make sure that they were locked and made inaccessible to the residents at all times. Cabinets storing detergent and all cleaning supplies were reviewed to make sure that they were locked and made inaccessible to the residents at all times.
Facility restrooms were toured. Grab bars and non skid mats were observed to be present and in good
Liza King
Charlie Yang
DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2026
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 13
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)
Page: 2 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CARING HEARTS ELDER CARE
FACILITY NUMBER: 392701647
VISIT DATE: 07/10/2026
NARRATIVE
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working order at this time.
Hot water temperatures were taken to make sure that the hot water being dispensed was within the allowed range of 105-120 degrees at all times.
A review of the facility medications for the residents was conducted. It was learned that all of the resident medications were centrally stored.
First aid kit, located in the facility medication locker located in the office area, was reviewed. It was observed that it did contain all of the required components and was in compliance at this time.
A review of the facility food supply was conducted. A tour of the facility pantry was conducted to make sure that there was a sufficient supply of 2-day perishables and 7-day non perishable food quantities on hand at all times.
It was learned that there was an additional refrigerator being used in the garage area.
Tour of the garage area was conducted. It was observed that this space was being used to store household items and personal items for the residents in care at this time.
Laundry area was toured. It was observed that the door leading into the laundry area did not have the ability to be locked at this time. It was observed that the cabinets within the laundry area were equipped with a locking mechanism to be able to store detergents and bleach so that they were inaccessible to the residents at all times.
A tour of the facility resident bedrooms was conducted. Furniture and furnishings were observed to be present and able to meet the needs of the residents at this time.
Linen closet, located in the facility hallway, was reviewed.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, (2) side gates, and all other exits was conducted.
A review of (6) facility resident files was conducted and noted on the following LIC 858.
A review of (2) facility staff files was conducted and noted on the following LIC 859.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.
The following civil penalties were assessed in the amount of $1000 on the following LIC 421.
Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 07/28/2026 09:37 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2026 at 01:50 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARING HEARTS ELDER CARE
FACILITY NUMBER: 392701647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that the hot water measured in the facility resident bathroom was registered at 125.2 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2026
Plan of Correction
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The facility designated staff person stated that the hot water heater will be turned down and the hot water will be measured for the next 72 hours. A statement of correction, along with proof of captured hot water temperature readings, will be completed and submitted into CCL by the due date for review by this LPA.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on record review, the licensee did not comply with the section cited above in [2] out of [2] facility staff files did not have updated proof of completed first aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2026
Plan of Correction
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The facility designated staff person stated that all facility staff providing care and supervision to the residents will be scheduled to undergo and complete first aid training. A statement of correction, along with proof of updated and completed first aid training, will be completed and submitted into CCL by the due date for review by this LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 07/28/2026 09:37 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2026 at 01:50 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARING HEARTS ELDER CARE
FACILITY NUMBER: 392701647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that there was only (1) other facility staff person on file to assist in maintaining adequate care and supervision to the residents in care for 24 hours/7 days a week which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2026
Plan of Correction
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The facility designated staff person stated that this facility will seek to hire and employ additional staff persons to cover all (3) shifts in order to provide adequate care and supervision to the residents at all times. A statement of correction, along with updated LIC 500, will be completed and submitted into CCL by the due date for review by this LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 07/28/2026 09:37 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2026 at 01:50 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARING HEARTS ELDER CARE
FACILITY NUMBER: 392701647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in [2] out of [2] facility staff files did not have documented proof of good health and cleared for TB which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2026
Plan of Correction
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The facility designated staff person stated that all facility personnel will be scheduled with their licensed medical professional to obtain proper TB clearance with good health. A statement of correction, along with proof of cleared TB and good health standing, will be completed and submitted into CCL by the due date for review by this LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 07/28/2026 09:37 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2026 at 01:50 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARING HEARTS ELDER CARE
FACILITY NUMBER: 392701647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in [2] out of [4] facility staff persons were not properly fingerprint cleared and associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2026
Plan of Correction
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The facility designated staff person stated that all facility staff persons will be fingerprint cleared and properly associated to this facility prior to being present or employed at this facility at all times. A statement of correction, along with proof of updated fingerprint clearance and proper association, will be completed and submitted into CCL by the due date for review by this LPA.
Type A
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in that the facility staff person did not have documented proof of initial/annual training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2026
Plan of Correction
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The facility designated staff person stated that all facility staff will receive and obtain the required hours for initial/ongoing training and have it available for review at all times. A statement of correction, along with proof of updated initial/annual training, will be completed and submitted into CCL by the due date for review by this LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 7 of 13
Document Has Been Signed on 07/28/2026 09:37 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2026 at 01:50 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARING HEARTS ELDER CARE
FACILITY NUMBER: 392701647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that there was not a adequate supply of 2-day perishable and 7-day nonperishable food quantities on hand at all times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2026
Plan of Correction
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2
3
4
The facility designated staff person stated that additional food items will be purchased to satisfy the requirement to have, on hand at all times, 2-day perishable and 7-day nonperishable food quantities. A statement of correction, along with proof of additional food items purchased, will be completed and submitted into CCL by the due date for review by this LPA.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that there weren't any medication records for the facility residents available for review at this time. It was observed that resident medications were pre poured and housed in week long dispensing pill boxes which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2026
Plan of Correction
1
2
3
4
The facility designated staff person stated that all resident medications will be originally stored in their bottles and packages and only punched out when dispensing to the residents at the designated times of the day. A statement of correction, along with proof of updated procedures will be trained unto the staff for no less than (1) hour in duration, will be completed and submitted into CCL by the due date for review by this LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 8 of 13
Document Has Been Signed on 07/28/2026 09:37 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2026 at 01:50 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARING HEARTS ELDER CARE
FACILITY NUMBER: 392701647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that the Medication Administration Record was not properly filled out and maintained to reflect that medications were properly handled, dispensed, and documented which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
1
2
3
4
The facility designated staff person stated that all facility staff will be trained and certified to be able to handle, dispense, and document the medications as ordered by the attending physicians for the facility residents. A statement of correction, along with updated proof of medication training, will be completed and submitted into CCL by the due date for review by this LPA.
Type A
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in [2] out of [6] facility resident files did not have complete and updated medical assessments which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2026
Plan of Correction
1
2
3
4
The facility designated staff person stated that an audit of all facility resident records will be conducted to make sure that they are complete and contain all of the required forms and documents at all times, especially an updated medical assessment to address all of the residents' care and supervisory needs. A statement of correction, along with copies of the updated medical assessments, will be completed and submitted into CCL by the due date for review by this LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 9 of 13
Document Has Been Signed on 07/28/2026 09:37 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2026 at 01:50 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARING HEARTS ELDER CARE
FACILITY NUMBER: 392701647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(c)(1)(A)
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in [1] out of [6] facility resident files did not have complete and updated medical assessments which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2026
Plan of Correction
1
2
3
4
The facility designated staff person stated that an audit of all facility resident records will be conducted to make sure that they are complete and contain all of the required forms and documents at all times, especially an updated medical assessment to address proper TB clearance. A statement of correction, along with copies of the updated medical assessments, will be completed and submitted into CCL by the due date for review by this LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 10 of 13
Document Has Been Signed on 07/28/2026 09:37 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2026 at 01:50 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARING HEARTS ELDER CARE
FACILITY NUMBER: 392701647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that there were several window screens that were ripped, torn, or had holes in them as well as a broken window located where the medication cabinet was located which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
1
2
3
4
The facility designated staff person stated that all window screens will be repaired/replaced to make sure that they do not have any tears, rips, or holes in them. In addition, the window where the medication cabinet is located will be replaced. A statement of correction, along with copies of receipts for services rendered in repairing/replacing the window screens and replacement of the window, will be completed and submitted into CCL by the due date for review by this LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 11 of 13
Document Has Been Signed on 07/28/2026 09:37 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2026 at 01:50 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARING HEARTS ELDER CARE
FACILITY NUMBER: 392701647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that facility personnel who were present and working at this facility did not have a complete and updated file made available for review upon request by this LPA which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
1
2
3
4
The facility designated staff person stated that all facility personnel files will be reviewed and updated to contain all required forms and documents. A statement of correction, along with copies of the updated facility personnel files, will be completed and submitted into CCL by the due date for review by this LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 12 of 13
Document Has Been Signed on 07/28/2026 09:37 AM - It Cannot Be Edited


Created By: Charlie Yang On 07/10/2026 at 01:50 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARING HEARTS ELDER CARE
FACILITY NUMBER: 392701647

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in [3] out of [6] facility resident files were not complete missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2026
Plan of Correction
1
2
3
4
The facility designated staff person stated that all facility resident files will be reviewed and updated to contain all required forms and documents. A statement of correction, along with copies of the updated facility personnel files, will be completed and submitted into CCL by the due date for review by this LPA.
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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
Page: 13 of 13