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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601118
Report Date: 03/19/2024
Date Signed: 03/19/2024 12:08:05 PM

Document Has Been Signed on 03/19/2024 12:08 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
SAN BRUNO RO, 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: 3DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver - Raymond JonesTIME COMPLETED:
12:30 PM
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On 03/19/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with caregiver Raymond Jones and explained the purpose of today's visit.

This is a 2 level facility. On the main floor is the kitchen, living room, one resident room, and office area adjacent to the front door. There is only one full bathroom in the facility and it is located on the main floor. The bathroom does contain the required items including non-slip flooring in the bathtub/shower. Water temperature is tested at 120F. Bathroom appeared clean. Kitchen is inspected and laundry area is also located in the kitchen area. Both areas are in place, clean, and functioning. Food supplies are inspected and per observations, there is not enough 7 day non-perishable and 2 day perishable food in place. LPA observed several boxes of Stouffers stuffing, 3 packages oflong grain rice in small packages, 6 cans of beans, 2 cans of cream of chicken, container of powdered lemonade as part of the 7 day supply. Fresh food supply is observed as one back of mixed salad, one bag of large carrots, one small container of tomatoes, and no juices or milks. In the kitchen there is a fire extinguisher last being inspected on 10/19/2021 but the charge level on the dial reads within the green/normal range. There are other random items observed as well in the refrigerator but does not lend towards the food supply. On the second floor there are two more resident rooms. Rooms contain required furniture items. Evacuation routes are free and clear of obstructions. Facility does not handle resident money according to staff present. LPA also observed smoke and carbon monoxide detectors in place. Knives are locked away and medications as well.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2024
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HEART 2 HEART - PEORIA
FACILITY NUMBER: 415601118
VISIT DATE: 03/19/2024
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Page 2 - LIC809

Files are reviewed. 3 of 3 resident files are reviewed. Files are available for review but they are not current and updated. LPA attempted to review staff files as well. LPA observed approximately 10 staff files but they were not current with the required documentation including training, first aid card, medical assessments and various items that are required per Title 22 regulation. According to staff present staff are trained on items including medications and emergency drills but there are no records to support. All staff records are to be updated. Additionally staff records do not indicate who is current staff and who is past. Per associations list there is only one person associated to the facility and that is the administrator/licensee Marcie Barber. There is no LIC500 that is available for LPA to review to confirm who is staff and how many there are supposed to be. The staff on site today indicated he did get a livescan done and has worked at the facility for at least 6 months. Administrator certificate is not available for LPA review. Client medications administration records are current as well as medications on site.

The following updated items are requested to be sent to the Department by 03/26/2024:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance
• Proof of control of property

Civil penalties are being assessed on this day at a rate of $100 x 5 days = $500 for staff not associated to the facility that is present on this day.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/19/2024 12:08 PM - It Cannot Be Edited


Created By: Jaime Vado On 03/19/2024 at 11:29 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HEART 2 HEART - PEORIA
FACILITY NUMBER: 415601118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2024
Section Cited
CCR
80065(i)(2)

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80065 Personnel Requirements - (i) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(2) Request a transfer of a criminal record clearance as specified in Section 80019(f). This requirement has not been met as evidenced by:
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Facility shall submit a plan to assoicate all currently working staff to the facility correctly via guardian or LIC9182. Plan shall be submitted to the department within 24 hours.
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Per observations made of associated staff, only one staff person is associated, the licensee/administrator herself, but no other staff. Staff on site on this day is not associated to the facility per reviewe of assoications. This poses a health and safety risk for residents in care as all other staff working in the facility are not associated.
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Civil penalty issued:
$100 x 5 days for the staff on site = $500
Type B
03/22/2024
Section Cited
CCR85075(d)(1)

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85076 Food Service - (d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This regulation has not been met as evidenced by:
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Facility shall submit a plan of correction to ensure such shortage is not to happen again in the future and the current supply should be increased as a part of this plan of correction. Receipts and photos of evidenc of showing replenishment is to be received by the department.
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Based on observations made of food supplies, LPA did not observe the appropriate quantity of food availible for resident use in case of emergencies. . LPA observed several boxes of Stouffers stuffing, 3 packages oflong grain rice in small packages, 6 cans of beans, 2 cans of cream of chicken, container of powdered lemonade as part of the 7 day supply. Fresh food supply is observed as one back of mixed salad, one bag of large carrots, one small container of tomatoes, and no juices or milks.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/19/2024 12:08 PM - It Cannot Be Edited


Created By: Jaime Vado On 03/19/2024 at 11:50 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HEART 2 HEART - PEORIA
FACILITY NUMBER: 415601118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2024
Section Cited
CCR
87866(a)

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87866 Personnel Records - (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This regulation has not been met as evidenced by:
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Facility shall submit a plan of correction to ensure that all staff files are current at all times with the required documentation for all staff associated and working in the facility including first aid cards. Plan shall be received by the department.
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Based on observations made, LPA reviewed approximately 10 staff files but each file was not complete with items required for staff working in the facility.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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