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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201144
Report Date: 11/18/2024
Date Signed: 11/18/2024 03:17:09 PM

Document Has Been Signed on 11/18/2024 03:17 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HEAVEN PLACE CARE HOMEFACILITY NUMBER:
019201144
ADMINISTRATOR/
DIRECTOR:		ADAMS, JACQUELINEFACILITY TYPE:
740
ADDRESS:14724 PEPPERDINE STTELEPHONE:
(510) 969-7966
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY: 6CENSUS: 4DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:33 PM
MET WITH:Estanislao Martinez, Care StaffTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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On 11/18/2024 at 12:33PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Estanislao Martinez, spoke with Administrator, Jacqueline Adams via telephone, and explained the purpose of the visit. The Administrator arrived at 1:25PM. Facility has census of 4. The facility’s fire clearance was approved for five (5) non-ambulatory and one (1) bedridden residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of five (5) bedrooms and two (2) bathrooms. One (1) bedroom occupied by staff. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 68 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 116.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/01/2024. Emergency Disaster Plan was last posted on 02/01/2024. First aid kit was observed to be complete. Fire drill was last conducted on 08/07/2024.

Continued LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HEAVEN PLACE CARE HOME
FACILITY NUMBER: 019201144
VISIT DATE: 11/18/2024
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Continued from LIC809.

Four (4) staff records were reviewed. During record review two (2) out of four (4) staff were missing FirstAid. LPA reviewed all four (4) resident records and sample of medications.

LPA requested updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/25/2024:


· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Client/Residents
· Liability Insurance
· Current Administrator’s Certificate


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

Continue LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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