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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804084
Report Date: 08/04/2022
Date Signed: 08/04/2022 11:40:10 AM

Document Has Been Signed on 08/04/2022 11:40 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 6DATE:
08/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant, Leonardo LalimTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 08/04/2022 at approximately 9:30 AM to conduct a prelicensing inspection. LPA was greeted and signed in by applicant Leonardo Lalim. Application was submitted for a change of ownership with residents in care. Current licensee Leni Stayman was also present during the inspection.

There are currently six residents in care, one resident is on hospice. Fire clearance was granted on 06/06/2022 for 6 nonambulatory residents. LPA toured facility with applicant. Facility was a comfortable temperature and exits were free from obstructions. Building and grounds were clean and in good repair. There are a total of four bedrooms, two of which are shared. Bedrooms had required furnishings. Bathrooms were equipped with necessary grab bars and nonslip floors. Extra linens and towels were available for residents. Facility has a large living room for activities and a large backyard. LPA observed sufficient perishable and nonperishable food. Water temperature was measured at 113.5 degrees F. Toxins were secured and inaccessible to residents. Medications were centrally stored and inaccessible. Facility had resident and staff files available for inspection upon request. LPA and applicant discussed the need for new admission agreements for new license. Fire extinguishers were last charged 01/04/2022. LPA observed necessary complaint and long term care ombudsman postings. Resident rights were prominently posted.

LPA conducted COMP III with applicant.

No deficiencies observed during today's inspection. LPA will notify application unit to proceed with licensing process.

Exit interview conducted with applicant and a copy of this report printed.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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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