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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804084
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:17:20 PM

Document Has Been Signed on 07/24/2024 03:17 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HEART TO HEART PROVIDER, LLCFACILITY NUMBER:
286804084
ADMINISTRATOR/
DIRECTOR:
LALIM, LEONARDOFACILITY TYPE:
740
ADDRESS:3684 JOMAR DRIVETELEPHONE:
(707) 226-5684
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 6DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:09 PM
MET WITH:Leonardo Lalim, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:31 PM
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Licensing Program Analyst (LPA) J. Macias arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Leonardo Lalim. Facility contact information was reviewed. All fees paid and current.

Currently six (6) residents in care. Facility has an approved fire clearance for six (6) non-ambulatory residents. There are 2 shared rooms and 2 private rooms. The facility has required emergency disaster plan.

At approximately 1:30pm LPA and Administrator toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and dated. Kitchen drawer with sharp knives was locked. Cleaning supplies were locked underneath kitchen sink and inaccessible to residents in care. All bedrooms were equipped with lighting, night stand, and chest of drawers per regulation. All bedrooms were clean and in good repair. Restrooms were equipped with necessary grab bars and non-slip bath mats. Extra hygiene products and linens were secured and readily available. Water temperature in sink accessible to residents in care measured at 108.6 and 110.8 degrees F, which is within the allowable range of 105 to 120 degrees F per regulation.

Fire extinguishers were last inspected September 25, 2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted July 19, 2024.

At approximately 2:00pm, LPA reviewed three (3) staff records. All staff files were found to be complete with all required documentation. First Aid and CPR certifications were all current.

At approximately 2:30pm, LPA reviewed five (5) resident files which were all found to be well organized, thorough, and contained the required documentation

At approximately 3:00pm LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet drawer. No deficiencies.

Continued on 809C...

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jacqueline Macias
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HEART TO HEART PROVIDER, LLC
FACILITY NUMBER: 286804084
VISIT DATE: 07/24/2024
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Continued from 809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: 8/24/2024

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

No deficiencies cited during this inspection. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jacqueline Macias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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