<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202915
Report Date: 02/19/2025
Date Signed: 02/19/2025 12:54:19 PM

Document Has Been Signed on 02/19/2025 12:54 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HEART TO HEART ADULT DAY CAREFACILITY NUMBER:
435202915
ADMINISTRATOR/
DIRECTOR:		BANWAIT, RUBINAFACILITY TYPE:
775
ADDRESS:450 MARATHON DRIVETELEPHONE:
(408) 460-1791
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY: 45CENSUS: 3DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator, Rubina BanwaitTIME VISIT/
INSPECTION COMPLETED:
01:00 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
Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced at 9:15AM to conduct the facility's annual inspection. LPA Tarin met with Administrator (ADM) Rubina Banwait and stated the purpose of the visit. ADM stated clients had not yet arrived at the facility for the day. ADM states the facility is expecting 3 clients later in the morning.

At 9:30AM LPA toured the reception area, where staff greet clients for the day. LPA observed 2 closets in the reception that contained supplies of gloves, masks, and hand sanitizer.

At 9:35AM LPA observed the arts and crafts center and observed a wooden table in the middle of the room with chair for clients. LPA observed games, books, magazines, art supplies, board games, and an electronic claw machine game that are accessible for clients.

At 9:40AM LPA observed 2 multi-purpose rooms and the kitchen. The 2 multipurpose rooms and kitchen are located within a shared open room. In Multipurpose room #1, LPA observed 6 tables with chairs, 2 recliners, and a TV. In Multipurpose room 2 LPA observed 2 tables with chairs for clients. LPA inspected the kitchen and observed knives and chemicals are locked and inaccessible to clients in care. LPA observed the digital temperature display on the refrigerator exterior door, refrigerator 37 degrees F and freezer 0 degrees F. LPA measured kitchen water temperature at 120 degrees F.

At 9:43AM LPA inspected the exit from Multipurpose room #1. LPA observed the exit from Multipurpose room #1, which leads to the front of the facility was free and clear of obstruction.

See LIC809C
NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: HEART TO HEART ADULT DAY CARE
FACILITY NUMBER: 435202915
VISIT DATE: 02/19/2025
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
26
27
28
29
30
31
32
At 9:45AM LPA inspected 2 client bathrooms, and 1 bathing/laundry room. LPA observed the 2 bathrooms had functioning lights, hand soap, paper towels and covered trash bins. Bathroom water temperature measured with a range 113.9 to 115 degrees F. LPA observed in the bathing/laundry room, a washer and dryer, and a bathtub and a shower for clients in care.

At 9:47AM LPA inspected the salon. LPA observed a chair and mirror, and hair dyer. ADM states the clients like to have their hair styled.

At 9:48AM LPA inspected the library, located next to the salon. LPA observed chairs and books for clients to read.

At 9:49AM LPA inspected the rest station. LPA observed a bed for clients and a shelf with boxes. ADM states the room is not currently being used by clients.

At 9:50AM LPA inspected the activity director office and observed a desk, computer and office supplies.

At 10:00AM ADM tested the facility's smoke detectors. The smoke detectors functioned properly when tested by the ADM. The facility's fire extinguisher was last inspected on 10/16/2024. LPA reviewed the facility's emergency drill logs. The last emergency drill was conducted on 1/13/2025.

At 10:15AM LPA reviewed 5 staff records. 4 out of 5 staff records were observed as complete to include fingerprint background clearance, health screening with TB results, and staff training. Staff S5 record did not contain CPR and First Aid training. ADM stated S5 would complete CPR and First Aid training and submit completion of training to the Department by 2/26/2025. LPA advised ADM to ensure all staff who provide direct care and supervision to clients obtain CPR and First Aid training.

At 11:15 AM LPA reviewed 5 client records. 5 out of 5 client records were reviewed as completed to include emergency contact information, physician's reports, and service plans.

A deficiency was cited during today's visit per California Code of Regulations, Title 22. See LIC809D. An exit interview was conducted with ADM Rubina Banwait. A copy of this report and appeal rights were provided to ADM during today's visit.
NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/19/2025 12:54 PM - It Cannot Be Edited


Created By: Marcella Tarin On 02/19/2025 at 12:10 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HEART TO HEART ADULT DAY CARE
FACILITY NUMBER: 435202915

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
82075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive and maintain current training in first aid and cardiopulmonary resuscitation from persons qualified by agencies including, but not limited to, the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview the Licensee did not comply with the section cited above. During staff record review, LPA observed Staff S5 did not have CPR and First Aid training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
1
2
3
4
Licensee stated S5 would complete CPR and First Aid training and submit proof of completion to the Department by POC due date 2/26/2025. Licensee stated the facility would submit a statement of understanding of the section cited to the Department by POC due date 2/26/2025.
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.
SUPERVISOR'S NAME:Jin Jackie
LICENSING EVALUATOR NAME:Marcella Tarin
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3