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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208905
Report Date: 05/14/2021
Date Signed: 05/14/2021 03:35:52 PM

Document Has Been Signed on 05/14/2021 03:35 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:HEART TO HEART FAMILY CARE CENTER LLCFACILITY NUMBER:
107208905
ADMINISTRATOR:VANG, CHAOFACILITY TYPE:
740
ADDRESS:672 E WRENWOOD AVETELEPHONE:
(559) 797-2166
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: 5DATE:
05/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Chao Vang, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) S. Moua and L. Cabrera conducted an Annual Inspection on this date. LPAs were met by Staff Kayleen Vang and stated the purpose of the visit. A tour of the facility was conducted. Administrator Chao Vang arrived later. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans with lid. Hand washing posters were observed by the bathroom sink. Bedrooms were checked and beds are six feet apart.

LPAs checked residents’ medications and observed a 30-day supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Administrator certification is current.

See LIC809D for citation issued today. Exit interview was conducted. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed with a read receipt request in lieu of a signature. LPAs explained that Administrator must select yes when prompted to send a read receipt.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2021
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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Document Has Been Signed on 05/14/2021 03:35 PM - It Cannot Be Edited


Created By: Lady Cabrera On 05/14/2021 at 11:16 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HEART TO HEART FAMILY CARE CENTER LLC
FACILITY NUMBER: 107208905

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87156(a)
An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185.

This requirement is not met as evidenced by: Annual fees were not paid.
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited. This poses a potential risk to the residents.
POC Due Date: 05/15/2021
Plan of Correction
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Administrator paid licensing fees during the inspection.
***Cleared***
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2021


LIC809 (FAS) - (06/04)
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