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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804084
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:34:48 PM

Document Has Been Signed on 10/27/2022 02:34 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, 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:
10/27/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Licensee/Administrator, Leonardo LalimTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos conducted an unannounced POST licensing inspection of this licensed senior care facility and was greeted by licensees.

LPA toured building and grounds which were found to be clean and in good repair. There are currently six residents in care, one resident is on hospice. Fire clearance was granted on 06/06/2022 for 6 nonambulatory residents. Facility was a comfortable temperature and exits were free from obstructions.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 113.0 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. Fire extinguishers were last charged 01/04/2022. LPA observed necessary complaint and long term care ombudsman postings. Resident rights were prominently posted.

LPA reviewed 6 resident files and 2 staff files. All files contained required documentation and training records.

LPA received current copy of Liability Insurance during visit.

No deficiencies cited during this inspection.

Exit interview conducted with licensee and a copy of this report sent to email on file.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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