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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804084
Report Date: 07/27/2022
Date Signed: 07/28/2022 12:34:44 PM

Document Has Been Signed on 07/28/2022 12:34 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:HEART TO HEART PROVIDER, LLCFACILITY NUMBER:
286804084
ADMINISTRATOR:LALIM, LEONARDOFACILITY TYPE:
740
ADDRESS:3684 JOMAR DRIVETELEPHONE:
(707) 226-5684
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: DATE:
07/27/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Leonardo Lalim, Applicant/Administrator; Ma. Corazon Lalim, ApplicantTIME COMPLETED:
02:30 PM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 6

COMP II Participants: Leonardo Lalim(Applicant/Administrator); Ma. Corazon Lalim(Applicant)

Interview Method: Telephone interview with CAB

Applicant/Administrator participated in COMP II. During COMP II, Applicants and Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Applicant and Administrator qualifications
3. Staff Qualifications - hiring procedures, responsibilities
4. Program policies -restricted/prohibited health conditions, medication management; incident reporting to CCLD; food service and management, Activities program
5. Grievances, Complaints, Community resources
6. Application document review and technical assistance- Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator Certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISORS NAME: Tracy Thompson
LICENSING EVALUATOR NAME: Ricmar Soriano
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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