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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600491
Report Date: 08/03/2023
Date Signed: 08/03/2023 12:00:31 PM


Document Has Been Signed on 08/03/2023 12:00 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:YOUNG IN HEART II, THEFACILITY NUMBER:
075600491
ADMINISTRATOR:CICAI, A.& D.FACILITY TYPE:
740
ADDRESS:4060 SIINO AVENUETELEPHONE:
(925) 825-7460
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 4DATE:
08/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Aurora Cicai, AdministratorTIME COMPLETED:
12:15 PM
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On 08/03/2023 at 10:45 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 6 Non Ambulatory.

LPA toured facility with Aurora including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. 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 110.7 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
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
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 II, THE
FACILITY NUMBER: 075600491
VISIT DATE: 08/03/2023
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At 10:50 AM, LPA reviewed 4 of 4 residents records. At 11:10 AM, LPA reviewed 2 of 6 staff records and 2 of 2 have current first aid training and associated to the facility. At 11:30 AM, LPA reviewed a sample of 4 of 4 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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
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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