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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601118
Report Date: 02/24/2022
Date Signed: 02/24/2022 04:04:25 PM

Document Has Been Signed on 02/24/2022 04:04 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HEART 2 HEART - PEORIAFACILITY NUMBER:
415601118
ADMINISTRATOR:BARBER, MARCIEFACILITY TYPE:
735
ADDRESS:333 PEORIA STREETTELEPHONE:
(904) 707-9707
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 3CENSUS: DATE:
02/24/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Marcie BarberTIME COMPLETED:
03:00 PM
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On this day at 1345hrs, Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced pre-licensing inspection visit. LPA met with administrator Marcie Barber nd explained purpose of today's inspection.

LPA toured the facility's building and grounds. This is a two floor facility. The ground floor is basement area for storage only. Residents reside on 1st and 2nd floor. Facility is equipped with combination smoke and carbon monoxide detectors on each floor. Fire extinguishers are last inspected on 10/19/2021 are are fully charged and available for use. Outside rear of facility contains a large backyard area for client use. There are no fountains or bodies of water present. Required postings are present.

LPA inspected the kitchen and dining room area. Dining room area is observed as clean and in order. Both fresh food and frozen food supplies are inspected and observed as in place in the kitchen. Dry goods/emergency food supplies are in place. LPA observed medication storage as locked in reception area desk. First aid kit is observed as complete. Client and staff files are observed as in order and complete.

LPA observed client rooms and they contain all the required furniture for their use. There is one client room on the 1st floor and two client room on the 2nd floor. Ambient room temperatures are comfortable through out the facility. Water temperature is measured at 120F in client full bathroom on 1st floor. Bathroom is equipped with non-slip mat in tub. Client toiletries are available. Staff do not reside on facility premises but staffing is available at all hours.

Facility is clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. No citations are issued.

Component III is conducted and report is reviewed with administrator Marcie Barber.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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