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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071441152
Report Date: 08/03/2023
Date Signed: 08/03/2023 10:39:28 AM

Document Has Been Signed on 08/03/2023 10:39 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:YOUNG IN HEART, THEFACILITY NUMBER:
071441152
ADMINISTRATOR:CICAI, AURORA IFACILITY TYPE:
740
ADDRESS:4070 SIINO AVENUETELEPHONE:
(925) 825-9685
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 2DATE:
08/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Aurora I Cicai, AdministratorTIME COMPLETED:
10:40 AM
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On 08/03/2023 at 9:00 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Aurora Cicai and explained the purpose of the visit. The facility’s fire clearance was approved for 1 Ambulatory and 5 Non Ambulatory.

LPA toured facility with Aurora including but not limited to bedrooms, bathroom, kitchen, common area and basement. The facility consists of 4 total bedrooms which are occupied by the residents. Administrator is a live in and occupies the downstairs portion of facility, residents do not have access to area. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 06/07/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 05/26/2023.

Report continues on 809 C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: YOUNG IN HEART, THE
FACILITY NUMBER: 071441152
VISIT DATE: 08/03/2023
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At 9:30 AM, LPA reviewed 2 of 2 residents records. At 9:40 AM, LPA reviewed 2 of 6 staff records and 2 of 2 have current first aid training and associated to the facility. At 10:07 AM, LPA reviewed a sample of 2 of 2 resident’s medications.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/24/2023:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610 E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate



No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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