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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208905
Report Date: 12/11/2024
Date Signed: 12/11/2024 03:23:22 PM

Document Has Been Signed on 12/11/2024 03:23 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:HEART TO HEART FAMILY CARE CENTER LLCFACILITY NUMBER:
107208905
ADMINISTRATOR/
DIRECTOR:		VANG, CHAOFACILITY TYPE:
740
ADDRESS:672 E WRENWOOD AVETELEPHONE:
(559) 797-2166
CITY:FRESNOSTATE: CAZIP CODE:
93710
CAPACITY: 6CENSUS: 5DATE:
12/11/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Chao VangTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 12/11/24 Licensing Program Analyst (LPA) Daiquiri Boyd visited the facility to complete the Annual Inspection and was greeted by Administrator (AD) Chao Vang.

LPA reviewed three staff files and three resident files. All required postings were observed. Smoke alarms and carbon monoxide detectors were observed to be operating. The fire and disaster drill was last performed in July of 2024.

LPAs requested Licensee to submit the following documents: LIC308, LIC309, LIC500, Proof of Liability Insurance by 12/20/2024.

Deficiencies cited on this day.

Administrators signature on this document confirms it's receipt.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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 2
Document Has Been Signed on 12/11/2024 03:23 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 12/11/2024 at 03:08 PM
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: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of three staff there were no current CPR training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
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Licensee will provide documentation that CPR training was completed by 12/31/24 and provide the proof to Licensing by the same date.
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:Daiquiri Boyd
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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