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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208905
Report Date: 05/24/2021
Date Signed: 05/24/2021 04:44:08 PM

Document Has Been Signed on 05/24/2021 04:44 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:
05/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Chao Vang, AdministratorTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Lady Cabrera conducted a subsequent Case Management visit to discuss information obtained from the annual visit conducted on 05/14/2021.

On 05/19/2021, Licensee provided updated LIC500 Personnel Record. Upon review, it was discovered Staff (S1) has been fingerprint cleared but is not associated to this facility and has been working. Administrator states that S1 will not returned to work until she is associated to the facility.

A civil penalty is being assessed in the amount of $100 per day, for a maximum of 5 days, for a total of $500. See LIC421BG for more details.



Deficiencies are being cited based on LPA's observation, interview conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plan of Correction (POC) were reviewed and developed with the Administrator. Administrator was informed that as a COVID-19 precautionary measure, LIC809, LIC809-D and LIC421BG and Appeal Rights will be emailed to the Administrator.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2021
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 05/24/2021 04:44 PM - It Cannot Be Edited


Created By: Lady Cabrera On 05/24/2021 at 11:10 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: 05/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2021
Section Cited
CCR
87355(c)

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87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another...
This requirement was not met as evidenced by:
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 On 05/19/2021, Licensee submitted LIC9182 for S1 to LPA to associate S1. S1 was taken off schedule.
***POC Cleared***
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LPA received an updated LIC500 from Licensee. Upon review, LPA found S1 not associated to the facility, which poses an potential health, safety or personal rights risk to persons in care.
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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: 05/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2021


LIC809 (FAS) - (06/04)
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