Heart and Soul Communities II

Type of visit: Case Management - Other

On 10/29/2025 at around 9:30 AM, Licensing Program Analysts (LPAs) Y. Brown and A. Gomez arrived to conduct a Case Management Closure visit and met with Licensee Ericka Tillis and explained the purpose of the visit. During the visit, LPAs inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining area, living area and storage areas. LPAs observed that there are still two (2) residents that require assistance residing at the facility. LPAs informed the Licensee that the two remaining residents that are still residing at the facility need to be relocated to licensed care. Licensee states that the residents families plan on taking them into their care. LPAs retrieved the facility License from the Licensee during the visit. LPAs explained to Licensee that the facility is now considered unlicensed and that any care being provided is now considered unlicensed. No Deficiencies cited during today's visit. Exit interview conducted and a copy of this report provided to Licensee.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Case Management - Health Checks

On 10/17/2025 at 11:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced for this Case Management - Health Checks visit. Upon entry into the facility, the LPA explained the purpose of the visit. During the visit, the LPA observed the residents R1 and R2 in their bedrooms. The LPA was updated on the correct time and coverage for when the Licensee will go on vacation. The LPA obtained the total facility census. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 20, 2025

Type of visit: Case Management - Legal/Non-compliance

On 10/17/2025 at 12:30 AM, Licensing Program Analyst (LPA) Y. Brown conducted a case management-legal non-compliance visit and met with Licensee Ericka Tillis and LPA explained the purpose of the visit. During the visit, LPA and Licensee discussed the update on the relocation of the residents, and LPA obtained the total census at the facility. Licensee stated that they have been working with the residents responsible parties and discussing their movement. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 17, 2025

Type of visit: Case Management - Legal/Non-compliance

On 10/10/2025 at 10:00 AM, Licensing Program Analyst (LPA) Y. Brown conducted a case management-legal non-compliance visit and met with Licensee Ericka Tillis and LPA explained the purpose of the visit. During the visit, LPA and Licensee discussed the update on the relocation of the residents, and LPA obtained the total census at the facility. Licensee stated that they have been working with the residents responsible parties and discussing their movement. Licensee discussed that they have contacted the Public Guardian to relocate the residents. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 10, 2025

Type of visit: Case Management - Legal/Non-compliance

On 10/2/2025 at 10:55 AM, Licensing Program Analyst (LPA) Y. Brown conducted a case management-legal non-compliance visit and met with Licensee Ericka Tillis and LPA explained the purpose of the visit. During the visit, LPA and Licensee discussed the update on the relocation of the residents, the residents ambulatory status and the total census at the facility. Licensee stated that they have been working with the residents responsible parties and Public Guardian to relocate the residents. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Case Management - Legal/Non-compliance

On 9/19/2025 at 11:00 AM, Licensing Program Analyst (LPAs) Y. Brown and J. Sampair conducted a case management-legal non-compliance visit and met with Licensee Ericka Tillis. Upon entry, the LPAs explained the purpose of the visit. During the visit, LPAs and Licensee discussed the update on the relocation of the residents. The LPAs observed three (3) residents at the facility and a fourth (R1) is in the hospital. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 19, 2025

Type of visit: Case Management - Legal/Non-compliance

On 9/5/2025 at 8:00 AM, Licensing Program Analyst (LPAs) Y. Brown and J. Sampair conducted a case management-legal non-compliance visit and met with Licensee Ericka Tillis and LPAs explained the purpose of the visit. During the visit, LPAs and Licensee discussed the update on the relocation of the residents, the residents ambulatory status and the total census at the facility. Licensee stated that they have been working with the residents responsible parties and Public Guardian to relocate the residents. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 5, 2025

Type of visit: POC

On 8/28/2025 at 9:25AM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct a POC (proof of correction) inspection. LPAs met with Licensee, Ericka Tillis informed her the reason for the visit. The following deficiencies was cleared by visit: - 87465(h)(6): LPAs received a written plan via email. - 87555(b)(8): Licensee threw away the expired food and purchased additional non-perishable food supplies. - 87211(a)(1): LPAs received self-certification during visit. LPA cleared deficiencies during visit and provided POC letters to Licensee. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Case Management - Legal/Non-compliance

On 8/22/2025, at 10:00 AM, Licensing Program Analysts (LPAs) James Sampair and Yasamin Brown arrived unannounced for this Case Management Legal/Non-compliance visit to deliver the letter dated 8/21/2025 to the Licensee Ericka Tillis. Upon entry, Licensee Ericka Tillis was notified of the purpose of the visit. During this visit, the LPAs delivered the letter to Licensee Ericka Tillis. No citations issued during this visit. Exit interview conducted with Licensee and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 22, 2025

Allegation investigated: Licensee serves residents expired food Licensee does not report incidents to appropriate parties

On 8/7/2025 at 2:10PM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegations above. LPA met with Licensee/Administrator, Ericka Tillis and explained the purpose of the visit. During the course of investigation, LPAs interviewed 6 residents, 4 staff, and witness. LPAs obtained and reviewed documents including police report, medical records for R1, and physician's report for R2. Licensee serves residents expired food There was large amounts of expired foods observed on licensing visits dated 5/29/2025 and 6/19/2025. (Continue on LIC9099C...) Substantiated Licensee does not report incidents to appropriate parties LPA G. Luk reviewed facility file and observed no incident reports were submitted when R1 went the hospital or when R2 had injuries. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided. Licensee physically abuses resident Police report stated R2 had bruising on the left side of the face; however, R2 consistently stated R2 was not assaulted and could not stay on topic due to dementia diagnosis. Deputies were informed by S1 that the closet door fell on R2’s head when R2 rummaged through the closet and the closet door broke. Interview with residents revealed they have not witnessed staff physically abuse residents. Interview with staff indicated they have not heard or witnessed physical abuse towards residents. Licensee does not assist resident's with obtaining medical care Interview with staff indicated that R2's bump or bruise was observed. However, S1 stated that medical attention was not needed for R2's injury at that time and R2 did not complain of pain. S1 also stated that R2 was evaluated after injury was observed and injury site was flat. Licensee did not assist resident with obtaining prescribed medication Interview with staff revealed that S1 handle’s residents’ medications including ordering and picking up prescription medications. Facility did not keep medication records; therefore, LPA was unable to determine if resident’s prescription medications were obtained and administered. Licensee does not maintain facility sanitary Interview with residents revealed that staff clean the facility daily. Interview with staff indicated that staff cleans every morning. LPAs observed facility has cleaning supplies available. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 15-AS-20250528121744

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Aug 15, 2025

General Food Service Requirements. All food shall be of good quality... This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by having expired non-perishable foods which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Licensee threw away the expired food and purchased additional non-perishable food supplies. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Aug 15, 2025

Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by not submitting incident reports which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Licensee has agreed to review reporting requirement and submit self-certification to CCLD by POC date.

Type of visit: Case Management - Deficiencies

On 8/7/2025 at 4:00PM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct a case management visit. LPAs met with Licensee/Administrator, Ericka Tillis and explained the purpose of the visit. While LPAs were at the facility for a complaint investigation (#15-AS-20250528121744), the following deficiency was observed. LPAs observed facility does not have centrally stored medication records available. Interview with staff indicated that facility did not keep medication records for residents. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Aug 15, 2025

Incidental Medical and Dental Care. The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having centrally stored records for residents available which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Licensee has agreed to create a plan to obtain the centrally stored records and submit the plan to CCLD by POC date.

Type of visit: Required - 1 Year

On 8/4/2025 at 12:45 pm, Licensing Program Analysts (LPAs) Y. Brown and J. Sampair arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator/ Licensee Ericka Tillis and explained the purpose of the visit. The administrator currently holds a certificate (#6042836740) that expires on 8/29/2027. LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. All outdoor and indoor passageways are kept free of obstruction. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Fire extinguisher was last serviced on 9/19/2024. The following deficiencies were observed: At 2:30 pm, LPAs observed missing CPR training from 0/4 staff members. At 2:35 pm, LPAs observed missing First Aid training from 0/4 staff members. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Aug 4, 2025

Type of visit: Case Management - Health Checks

On 8/04/2025, at 12:45 PM, Licensing Program Analyst (LPAs) James Sampair and Yasamin Brown arrived unannounced to conduct a Plan of Correction (POC) visit. Upon arrival, the LPAs stated the purpose of the visit to Licensee Ericka Tillis. LPAs toured the facility, including the residents' bedrooms, bathrooms, common area, kitchen, and outdoor areas. 7 days of non-perishable and 2 days of perishable food supplies were present. No citations were issued Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 4, 2025

Type of visit: POC

On 8/04/2025, at 12:45 PM, Licensing Program Analyst (LPAs) James Sampair and Yasamin Brown arrived unannounced to conduct a Plan of Correction (POC) visit. Upon arrival, the LPAs stated the purpose of the visit to Licensee Ericka Tillis. On 7/18/2025, LPAs Brown and Luk conducted a Case Management visit during which 1 deficiency was cited. The 1 deficiency was cleared during this visit. No citations were issued Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 4, 2025

Type of visit: Case Management - Health Checks

On 7/18/2025 at 3:00 pm, Licensing Program Analysts (LPAs) Y. Brown and G. Luk arrived unannounced to conduct a health and safety check. LPAs met with Licensee/Administrator, Ericka Tillis and informed her the reason for visit. LPAs toured the facility including but not limited to resident's bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 106.2 degrees F in a resident's bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. The following deficiency was observed: At 3:47 pm, LPAs observed downstairs residents shared restroom door and door handle were in disrepair. Deficiency are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. During the visit, LPAs also hand delivered a copy of the civil penalty invoice to the licensee due to mail was undeliverable. LPAs were informed by licensee that the facility address has been changed recently and licensee provided current facility address to LPAs. Exit interview conducted with Licensee/Administrator and a copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Jul 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(c) · Plan of correction due date: Jul 31, 2025

87307 Personal Accommodations and Services (c) Individual privacy shall be provided in all toilet, bath and shower areas. This requirement was not met as evidence by: Based on observation, the Licensee did not comply with the section cited above by having the resident's bathroom door and door handle in disrepair which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 18, 2025

Plan of correction: Licensee/Administrator agreed to get the door and door handle repaired and submit photo proof to CCLD by POC date.

Type of visit: Case Management - Health Checks

On 6/18/2025 at 11:00 am, Licensing Program Analysts (LPAs) Y. Brown and J. Sampair arrived unannounced to conduct a health and safety check as a result of the accusation issued on 5/27/2025. LPAs met with Licensee/Administrator, Ericka Tillis and explained the purpose for the visit. LPAs toured facility including but not limited to resident's bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 101.5 degrees F in the facilities kitchen sink. LPAs observed 7-days of non-perishable and 2-days of perishable food supplies were sufficient. LPAs observed the following deficiencies: At 2:00 PM, LPAs measured that the temperature of the freezer was 9 degrees Fahrenheit and the refrigerator was 49.3 degrees Fahrenheit. At 5:00 PM, LPAs observed S1 has fingerprint clearance but is not associated with the facility. Continued on LIC809C... Continued from LIC809. Immediate civil penalties of $250 and $500 were assessed. The deficiencies were cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties Exit interview conduct. A copy of this report, appeal rights, LIC421BG, and LIC421FC provided.the state’s words, verbatim · CDSS document, Jun 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(21) · Plan of correction due date: Jun 25, 2025

87555 General Food Service Requirements: (b)(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C). This requirement was not met as evidenced by: The temperature of one of the freezers was 9 degrees and one of the refrigerators was 49.3 degrees Fahrenheit. All of the refrigerators and freezers were observed to be unclean.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: For all of the refrigerators and freezers in the facility, the Licensee agreed to reduce freezer temperatures to 0 degrees, the refrigerators to 40 degrees and attest to the proper temperature, and to thoroughly clean them. The Licensee shall submit the photos of every one after they have been cleaned to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jun 19, 2025

(e) All individuals subject to a criminal record review... shall prior to working.. in a licensed facility: (3) Request a transfer of a criminal record clearance... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having S1 associated to the facility, which poses an immediate health and safety risk to person in care.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: Administrator agreed to send LIC9182 and S1 identification to CCLD to be associated.

Type of visit: Case Management - Legal/Non-compliance

On 6/18/2025, at 11:00 AM, Licensing Program Analysts (LPAs) James Sampair and Yasamin Brown arrived unannounced for this Case Management Legal/Non-compliance visit, concerning the California Department of Social Services (CDSS) Accusation #7525116301 dated 5/27/2025. Upon entry into the facility, the LPAs stated the purpose of the visit to Licensee Ericka Tillis. On 6/9/2025, LPAs Yasamin Brown and Laura Hall observed that the CDSS Accusation was not posted in a conspicuous place. Additionally, the Licensee had not provided notice to the responsible party for any of the residents nor for the local long-term care ombudsman. During this visit, the LPAs verified that the CDSS Accusation received by Licensee Ericka Tillis on 5/29/2025 was posted in a conspicuous place. 2 A-Type citations were issued during this visit (for additional details refer to 809-D). Exit interview conducted with Licensee and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.38(b)(1) · Plan of correction due date: Jun 19, 2025

Posting of licensing reports; disclosure to new residents (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident's responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1) The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. This requirement is not met as evidenced by: On 6/09/2025, LPAs Yasamin Brown and Laura Hall informed 3 responsible parties of the CDSS Accusation #7525116301 dated 5/27/2025 and received by Licensee Ericka Tillis on 5/29/2025. Zero of the 3 responsible parties had been informed of the Accusation.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: Cleared during visit.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.38(a) · Plan of correction due date: Jun 19, 2025

Posting of licensing reports; disclosure to new residents (a) Each residential care facility for the elderly shall place in a conspicuous place copies of all licensing reports issued by the department within the preceding 12 months. . . . This requirement is not met as evidenced by: On 6/09/2025, LPAs Yasamin Brown and Laura Hall observed that the CDSS Accusation #7525116301 dated 5/27/2025 and received by Licensee Ericka Tillis on 5/29/2025 had not been posted in a conspicuous place.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: Cleared during visit.

Type of visit: Case Management - Health Checks

On 6/9/2025 at 10:35am, Licensing Program Analysts (LPAs) L. Hall and Y. Brown arrived unannounced to conduct a health and safety check as a result of a priority 1 complaint. LPAs met with Licensee/Administrator, Ericka Tillis and informed her the reason for visit. LPAs toured facility including but not limited to resident's bedrooms, bathrooms, common area, kitchen, and outdoor area. LPAs observed one (1) resident upstairs bedroom and the other seven (7) residents downstairs in the common area. S1 stated she did receive the accusation via mail, but was not aware it had to be posted. S1 stated five (5) of the eight (8) residents have been notified. S1 also stated she will notify the other three (3) residents' responsible parties regarding the accusation. No deficiencies cited during visit. Exit interview conduct with Licensee/Administrator and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 9, 2025

Type of visit: Case Management - Health Checks

On 5/29/2025 at 2:00PM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct a health and safety check as a result of a priority 1 complaint. LPAs met with Licensee/Administrator, Ericka Tillis and informed her the reason for visit. LPAs toured facility including but not limited to resident's bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 106.2 degrees F in a resident's bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Smoke and Carbon monoxide detectors observe. Fire extinguisher was observed to be full and last serviced on 3/7/2025. At 1:52PM, LPAs observed S1 is not fingerprint cleared after reviewing Guardian system. Civil penalty of $500 is being assessed. At 3:15PM, LPAs observed unlocked medication in the refrigerator and on the counter in the kitchen. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with Ericka Tillis. A copy of this report, civil penalty, and appeal rights provided.the state’s words, verbatim · CDSS document, May 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 30, 2025

Criminal Record Clearance. Obtain a California clearance or a criminal record exemption as required by the Department or...This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having S1 fingerprint cleared which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Licensee has agreed to follow up with Guardian regarding S1's fingerprint clearance and submit contact email/document to CCLD by POC date. Civil penalty of $500 is being assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR874665(h)(2) · Plan of correction due date: May 30, 2025

Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible ...This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by having unlocked medications which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Licensee locked up and/or discarded the medications during inspection. Deficiency cleared.

Type of visit: POC

On 4/14/2025 at 1:30 PM, Licensing Program Analyst (LPAs) James Sampair and Yasamin Brown arrived unannounced to conduct a Plan of Correction (POC) visit. Upon arrival, the LPAs stated the purpose of the visit to Licensee Ericka Tillis. On 4/4/2025, LPAs Sampair and Brown conducted a Case Management visit during which 4 deficiencies were cited. all 4 of the deficiencies were cleared during the visit. No citations were issued Exit interview conducted and a copy provided.the state’s words, verbatim · CDSS document, Apr 14, 2025

Type of visit: Case Management - Health Checks

On 04/04/2025, at 2:30 PM, Licensing Program Analysts (LPAs) James Sampair and Yasamin Brown arrived unannounced to conduct a Case Management - Health Check inspection. Upon entering the facility, the LPAs explained the purpose of visit to Licensee Ericka Tillis. The LPAs toured the facility with the Licensee. The LPAs inspected both floors of the facility, including both of the kitchens, dining areas, restrooms, community living spaces, bathrooms, resident rooms, and the grounds of the facility. Temperature in the upstairs kitchen was measured at 73.8 degrees Fahrenheit. Fire extinguisher was fully charged and last replaced on 02/11/2025. The combination carbon monoxide and smoke detector was fully operational. The facility remains over capacity, care of persons classified as non-ambulatory in a facility licensed to care for ambulatory only persons, unpaid annual and late fees, and absence of a certified administrator. In addition to the existing deficiencies listed above, 2 new Type-A and 2 new Type-B deficiencies, and a $500 Civil Penalty were issued during the visit (for details refer to LIC 809-D and LIC 421BG). The exit interview was conducted and a copy of this report provided. Facility is subject to ongoing daily civil penalties until proof of corrected deficiencies have been sent to Community Care Licensing (CCL).the state’s words, verbatim · CDSS document, Apr 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: Apr 11, 2025

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on observation, the Licensee did not have a one week supply of nonperishable and 2 days of perishable foods maintained on the premises, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Apr 4, 2025

Plan of correction: Licensee agreed to purchase food and submit photo and receipt to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(21) · Plan of correction due date: Apr 11, 2025

87555 General Food Service Requirements (b)(21) Freezers of adequate size shall be maintained at a temperature of 0-degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean, and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by: The temperature of one of the freezers was 13.8 degrees and one of the refrigerators was 43.2 degrees Fahrenheit. All of the refrigerators and freezers were observed to be unclean.the state’s words, verbatim · CDSS document, Apr 4, 2025

Plan of correction: For all of the refrigerators and freezers in the facility, the Licensee agreed to reduce freezer temperatures to 0 degrees, the refrigerators to 40 degrees and attest to the proper temperature, and to thoroughly clean them. The Licensee shall submit the attestation and photos of every one after they have been cleaned to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.17(c)(1)(A) · Plan of correction due date: Apr 5, 2025

(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility. This requirement is not met as evidenced by: Family member S1 living at the facility is 18 years old and did not have fingerprint clearance, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 4, 2025

Plan of correction: Licensee promised to have S1 fingerprinted and associated with the facility on or before the due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Apr 5, 2025

Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: With medications stored unlocked in the refrigerators, the licensee did not comply with the section above, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 4, 2025

Plan of correction: Licensee promised to put medications stored in refrigerator in a locked box on or before the due date.

Type of visit: POC

On February 12, 2025 at 3:30 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a Plan of Correction (POC) visit. Upon arrival, the LPA stated the purpose of the visit to Licensee Ericka Tillis. On January 29, 2025, LPAs Clancy-Czuleger and Sampair conducted a Case Management visit during which 7 deficiencies were cited. 1 deficiency was cleared during the visit. 6 of the deficiencies were not cleared during the visit. Civil Penalties for deficiencies not cleared during visit: · Due 1/31/25 for CCR 87204(a): 14 days at $100 per day totals $1,400 – Over Capacity · Due 1/31/25 for CCR 87355(d): 12 days at $100 per day totals $1,200 – No Certified Administrator Present · Due 1/31/25 for CCR 87204(b): 14 days at $100 per day totals $1,400 – Care of Persons Classified as Non-Ambulatory in Ambulatory Only Facility · Due 1/31/25 for CCR 87705(c)(1): 14 days at $100 per day totals $1,400 – Care of Persons with Dementia in Ambulatory Only Facility · Due 1/31/25 for HSC 1569.185(a)(1): 12 days at $100 per day totals $1,200 – Payment of Annual Fees 2019-2024 · Due 1/31/25 for HSC 1569.185(b)(1)(F): 12 days at $100 per day totals $1,200 – Payment of Late Fees 2019-2024 Civil Penalties totaling $7,800 have been assessed today for failure to meet POC due dates for the deficiencies above. Facility is subject to ongoing daily civil penalties until proof of corrected deficiencies have been sent to Community Care Licensing (CCL). Continued on LIC 809-C… ...Continued from LIC 809 Deficiencies are cited from Title 22 California Code of Regulations (see 809D's). Failure to submit proof of correction along with the LIC9098 Proof of Correction by due date may result in additional civil penalty. Exit interview conducted. A copy of this report, appeal rights, and LIC 421FCs provided.the state’s words, verbatim · CDSS document, Feb 12, 2025

Type of visit: Case Management - Legal/Non-compliance

On this day, January 29, 2025 at 10:40 am, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and J. Sampair arrived unannounced to conduct case management inspection as part of monitoring plan from Non-compliance Conference held on November 07, 2024. LPA met with Licensee Erika Tillis, and informed the reason for visit. LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms. LPA inspected the food supples and observed good for 2 days of perishables and 7 days of non-perishables. During the health and safety check, LPA observed a total of 3 staff members and 9 residents at the facility. The following deficiencies are observed: Annuals fees are outstanding for 2019, 2020, 2021, 2022, 2023 and 2024. Late fees have been assessed and are outstanding for 2019, 2021, 2022, 2023 and 2024. S1 does not have a valid Administrator Certificate S3 is not fingerprint cleared and associated to the facility Facility is caring for residents who are non-ambulatory Facility is caring for residents beyond the conditions and limitations specified on the license Facility is licensed for only ambulatory residents, but is caring for residents who are diagnosed with dementia Continued on 809-C... ...Continued from 809 Deficiencies are cited from Title 22 California Code of Regulations (see 809D's). A $500.00 civil penalty is assessed for deficiency #87355(d). A $750 immediate civil penalty assessed for repeat citations 87204(b), 87705(c)(1) and 87204(a). Failure to submit proof of correction along with the LIC9098 Proof of Correction by due date may result in additional civil penalty. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87406(a) · Plan of correction due date: Jan 31, 2025

All individuals subject to criminal record review shall be fingerprinted... Criminal Record Statement... (3) The licensee shall submit these fingerprints... for the purpose of searching the records... prior to the individual's employment, residence, or initial presence in the facility. Based on record review the Licensee did not comply with the section cited above in having S3 fingerprinted before working at facility which poses a potential immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Administrator agreed to get S3 fingerprinted and submit proof to CCLD by POC date. A $500.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(d) · Plan of correction due date: Jan 31, 2025

(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not having a valid administrators certificate which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: By POC date Administrator agrees to submit documents for certificate renewal and notify CCLD

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(b) · Plan of correction due date: Jan 31, 2025

Limitations - Capacity and Ambulatory Status (b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms a review of the records revealed that the facility licensed for all ambulatory residents, but 5 of 6 residents currently living in the facility are nonambulatory, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: On or before the due date, a plan of relocation for the non ambulatory residents will be submitted to CCLD.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(c)(1) · Plan of correction due date: Jan 31, 2025

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills. a review of the records revealed that 4 of 6 residents are diagnosed with dementia, but the facility is licensed for only ambulatory residents, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: On or before the due date, the nonambulatory residents will leave facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Jan 31, 2025

A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time... This requirement is not met as evidenced by… Based on observations LPA's observed 9 residents at the care facility being cared for.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: On or before the due date, the addtional residents will leave facility.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.185(a)(1) · Plan of correction due date: Jan 31, 2025

(a)(1) An application fee adjusted by facility and capacity shall be charged by... After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. This requirement was not met as evidenced by: LPA conducted a records check via LIS which revealed outstanding annual fees due to the department which poses a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee to make payment and provide proof of that payment to CCL by the POC date. Outstanding Annual Fees: $2970.00

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569(b)(1)(f) · Plan of correction due date: Jan 31, 2025

(b) (1)...fees set forth in subdivision (a), the department shall charge all of the following fees: (F) A late fee that represents an additional 50 percent of the established current annual fee when a licensee fails to pay the current annual licensing fee on or before the due date as indicated by postmark on the payment. This requirement was not met as evidenced by: LPA conducted a records check via LIS which revealed outstanding late fees due to the department which poses a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Licensee to make payment and provide proof of that payment to CCL by the POC date. Outstanding Annual Fees: $1,482.00

Type of visit: POC

On 1/29/2025 at 10:30 AM, Licensing Program Analysts (LPAs) James Sampair and Jill Clancy-Czuleger arrived unannounced to conduct a Plan of Correction (POC) visit. Upon arrival, the LPAs stated the purpose of the visit to Licensee Ericka Tillis. On 01/13/2025, LPA Sampair conducted a Case Management visit during which 4 deficiencies were cited. 1 deficiency was cleared during the visit. 3 of the deficiencies were not cleared during the visit: resident records missing, no emergency/disaster drill conducted, and the hot water temperature was measured at 133.7 degrees Fahrenheit. Civil Penalties for deficiencies not cleared during visit: Due 1/14/2025 for 87303(e)(2) 16 x $100 per day = $1,600 Due 1/14/2025 for 87506(a) 16 x $100 per day = $1,600 Due 1/27/2025 for 1569.695(c) 2 x $100 per day = $200 Civil Penalties in the total amount of $3,400 have been assessed today for failure to meet POC due dates for the deficiencies above. Facility is subject to ongoing daily civil penalties until proof of corrected deficiencies have been sent to CCL. Exit interview conducted. A copy of this report, appeal rights, and LIC 421FCs provided.the state’s words, verbatim · CDSS document, Jan 29, 2025

Allegation investigated: Facility staff speak inappropriately to residents Facility staff yell at residents

On 1/13/2025 at 8:15 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to deliver finding for the above allegations and met with Licensee Ericka Tillis. LPA explained to Ms. Tillis the purpose of the visit. During the course of investigation, LPA L. Fontanilla conducted the 10-day visit, obtained records and interviewed the Administrator, five residents, two staff and responsible persons for two residents. On 7/29/2024, LPA Fontanilla spoke with the Reporting Party (RP) who states that RP did not physically witness but heard voices from the facility. RP added that the voice was saying, “Are you going to hurt me?” and a “Yes” response was heard. RP added that days after calling in the complaint to Community Care Licensing (CCL), RP observed a fire engine arrive and the facility has been quiet since then. Continued on LIC 809-C . . . Unsubstantiated . . . Continued from LIC 809 Based on interviews conducted, 3 out of 5 residents denied observing staff yelling at residents. The Administrator and two staff interviewed denied yelling or speaking to residents inappropriately. The Licesee states that she takes care of a family member who has illness and needed to be picked up by an ambulance a few days before LPA visit. On 10/14/2024, LPA interviewed responsible persons for R5 and R6, residents with a dementia diagnosis. Both RPs denied witnessing or hearing staff yelling and/or speaking inappropriately to the residents. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. There was no deficiency associated with this complaint. A copy of this report was provided to the Licesee.the state’s words, verbatim · CDSS document, Jan 13, 2025 · control 15-AS-20240722112140

Type of visit: Case Management - Legal/Non-compliance

On 1/13/2025 at 8:15 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a Case Management inspection as part of the monitoring plan from Non-compliance Conference held on November 07, 2024 with Licensee Ericka Tillis. Upon arrival, the LPA informed the Licensee of the reason for visit. The LPA inspected the interior and exterior of the facility, including the kitchens upstairs and downstairs, the dining room areas, community living spaces, restrooms, resident rooms, storage areas, the garage, and the grounds of the facility. There was more than the required minimum of 2 days of perishable and 7 days of nonperishable food at the facility. The hot water temperature was measured in the upstairs kitchen at 137.3 degrees Fahrenheit (Type-A Citation). The upstairs dining room temperature was measured at 70.0 degrees Fahrenheit. The fire extinguisher was last serviced on 10/30/2023 (Type-B Citation). LPA observed a total of 3 staff members and 9 residents at the facility. Continued on LIC 809-C . . . Continued from LIC 809 1 Type-A and 3 Type-B deficiencies cited and 2 Civil Penalties for Repeat Violations for $250 each were issued during the visit. Deficiencies and plan and proof of corrections were discussed with the Licensee. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809-D. Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights, LIC 9098 Proof of Correction form, and copy of this report were provided.the state’s words, verbatim · CDSS document, Jan 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jan 14, 2025

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) … Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to … not less than 105 degree F … and not more than 120 degree F. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above. The hot water temperature was measured at 137.3 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2025

Plan of correction: On or before the due date, the Licensee shall send proof to the LPA that the temperature of the hot water has been reduced to between 105 and 120 degrees Fahrenheit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: Jan 27, 2025

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above. The last time the fire extinguisher was serviced was 10/30/2023, beyond the annual inspection time limit, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2025

Plan of correction: On or before the due date, the Licencee shall send proof to the LPA that the fire extinguisher has been serviced or replaced.

From the deficiency page — Deficiency type: Type B · Section cited: HSC87506(a) · Plan of correction due date: Jan 27, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on record review, the Licensee did not comply with the section cited above. A separate, complete, and current record for each resident in the facility is not readily available to licensing agency staff, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2025

Plan of correction: On or before the due date, the Licencee shall send conservator names and contact information for each conservator, along with copies of the eviction letters, so the LPA will be able to call to confirm and to establish possible dates by when the non-ambulatory residents will be leaving the facility.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Jan 27, 2025

1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter ... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill This requirement is not met as evidenced by:. Based on record review, the Licensee did not comply with the section cited above. A record of the drills was not readily available to licensing agency staff, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 13, 2025

Plan of correction: On or before the due date, the Licencee shall send proof to the LPA that the emergency drills have been conducted on a quarterly basis over the past year and if those records are not available, then proof that 1 drill for every shift has been conducted at the facility and a schedule for the other drills during 2025.

Type of visit: Case Management - Health Checks

On this day, December 30, 2024 at 2:40 am, Licensing Program Analyst (LPA) Clancy-Czuleger arrived unannounced to conduct case management inspection as part of monitoring plan from Non-compliance Conference held on November 07, 2024. LPA met with Licensee Ericka Tillis, and informed the reason for visit. LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms, front, side and backyard. LPA inspected the food supples and observed good for 2 days of perishables and 7 days of non-perishables. During the health and safety check, LPA observed a total of 2 staff members and 9 residents at the facility. LPA confirmed that residents were served notices. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 30, 2024

Type of visit: Case Management - Health Checks

On this day, November 18, 2024 at 1:25 am, Licensing Program Analyst (LPA) Clancy-Czuleger arrived unannounced to conduct case management inspection as part of monitoring plan from Non-compliance Conference held on November 07, 2024. LPA met with Licensee Ericka Tillis, and informed the reason for visit. LPA toured the facility inside out. LPA inspected the living room, dining area, kitchen, bathrooms, residents rooms, front, side and backyard. LPA inspected the food supples and observed good for 2 days of perishables and 7 days of non-perishables. During the health and safety check, LPA observed a total of 2 staff members and 9 residents at the facility. LPA confirmed that residents were served notices. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 18, 2024

Type of visit: Case Management - Other

On 10/21/2024 at 8:30 AM, Licensing Program Analysts (LPAs) James Sampair and Ardalan Gharachorloo conducted a Case Management visit of the facility. The LPAs observed that residents R7 through R11 were living at this facility, though they are residents of Heart & Soul Communities #015601242. 1 Type-B citation issued during the inspection. Deficiencies are cited per Title 22 California Code of Regulations as listed on the LIC 809-Ds. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties. Exit interview conducted, a copy of this report, and the appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Oct 29, 2024

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: During the record review, the Licensee had no records available for the LPAs to review for residents R7 through R11, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2024

Plan of correction: On or before the due date, the Licensee shall send proof to LPA Sampair that resident records for all residents are at the facility.

Type of visit: POC

On 10/21/2024 at 9:00 AM, Licensing Program Analysts (LPAs) James Sampair and Ardalan Gharachorloo conducted a Plan of Correction (POC) inspection. Upon entry into facility, LPAs explained the purpose of the visit to Licensee Ericka Tillis. The Licensee failed to send documentation of POC clearance from the citation issued 10/10/2024 to LPA Sampair. During the inspection of the facility, the medications were in locked storage, however, the signage on the first and second floors was not posted. Per Title 22 California Code of Regulations, a $1,100.00 Civil Penalty was assessed for the repeat of a prior violation of Section 87309(b) first issued on 9/24/2024 that was due on 10/11/2024. For additional details, refer to the LIC 421FC form. Failure to submit proof of corrections may result in additional civil penalties. Exit interview conducted, a copy of this report, and the appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 28, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above. A toilet seat had a large crack, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2024

Plan of correction: Licensee corrected during the visit.

Type of visit: Case Management - Deficiencies

On 10/10/2024 at 08:30 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger and J. Sampair arrived unannounced to conduct a Case Management. LPA met with Ericka Tillis, Administrator. While at the facility on 10/07/2024 LPA J. Sampair observed that there were 11 residents in the care facility. S1 stated that only 6 were residents of this home and the other 5 were residents for the other home Heart and Sol Communities (15601242) that's located at 3770 Sutter st. Oakland. When arriving at the facility on 10/10/2024 LPA's were informed by staff that they had 7 residents. It was also observed that there were chemicals left under the upstairs kitchen sink and bathroom sink unlocked and accessible to residents. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809D's. A $250.00 civil penalty is assessed for each of the repeat violation of deficiency section #'s 87204(a) and 87309(a). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties. Exit interview conducted. Appeal Rights, LIC421FC, and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 10, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Oct 11, 2024

A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time... This requirement is not met as evidenced by… On 10/07/2024 LPA's observed 6 residents, and 5 visiting residents at the care facility being cared for. On 10/10/2024 LPA's were informed that there are 7 residents.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: A mandatory meeting will be held at a later date. This is a repeat violation of the same citation issued by LPA J. Clancy-Czuleger on 09/10/2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR87309(a) · Plan of correction due date: Oct 17, 2024

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by… On 10/07/2025 LPAs's observed chemicals left unlocked and accessible under the upstairs kitchen sink and bathroom sink.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: This is a repeat violation of the same citation issued by LPA J. Clancy-Czuleger on 09/10/2024 and by LPA J. Sampair on 09/24/2024. A civil penalty of $250 is being assessed for this repeat violation

Type of visit: Case Management - Deficiencies

On 10/10/2024 at 8:30 AM, Licensing Program Analysts (LPAs) James Sampair and Jill Clancy-Czuleger arrived unannounced to conduct a Case Management – Deficiencies inspection of the facility. Upon entry the LPAs informed Licensee Ericka Tillis of the reason for the visit. 1 Type-A and 2 Type-B citations issued during the inspection. Deficiencies are cited per Title 22 California Code of Regulations as listed on the LIC 809-Ds. $250.00 Civil Penalty assessed for repeat violation of Section 87309(b). $500.00 Immediate Civil Penalty assessed for serious violation of Section 87204(b). Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties. Exit interview conducted, a copy of this report, and the appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 10, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(b) · Plan of correction due date: Oct 17, 2024

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. This requirement is not met as evidenced by: On 10/7/2024, LPAs Sampair and Doidge observed medications in an open and not locking container on cabinet in 2nd floor dining room, which posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: On or before the due date, the Licensee shall send proof to LPA Sampair that locked storage for all medications, for residents and for personal use, has been obtained and signs posted both upstairs and downstairs showing that written procedures in large print have been printed and posted both upstairs and downstairs for employees, personal residents, and visitors to follow when storing medications.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87204(b) · Plan of correction due date: Jan 10, 2025

Limitations - Capacity and Ambulatory Status (b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement is not met as evidenced by: On 9/24/2024, a review of the records revealed that the facility licensed for all ambulatory residents, but 5 of 6 residents currently living in the facility are nonambulatory, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: On or before the due date, the nonambulatory residents will leave facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(1) · Plan of correction due date: Jan 10, 2025

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills. This requirement is not met as evidenced by: On 9/24/2024, a review of the records revealed that 4 of 6 residents are diagnosed with dementia, but the facility is licensed for only ambulatory residents, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: On or before the due date, the nonambulatory residents will leave facility.

Type of visit: POC

On 10/7/2024 at 1:30 PM, Licensing Program Analysts (LPAs) James Sampair and David Doidge conducted a Plan of Correction (POC) inspection. Upon entry into facility, LPAs explained the purpose of the visit to Caregiver Keiyata Pettway. The Licensee failed to provide documentation to LPA Sampair on 3 of the 5 citations issued during the 9/24/2024 visit. Failure to send proof of correction to the LPA resulted in the issue of 3 civil penalties (for details, refer to the LIC 421FC forms). Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 7, 2024

Type of visit: Required - 1 Year

On 9/24/2024 at 10:00 AM, Licensing Program Analysts (LPAs) David Doidge and James Sampair arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPAs stated the purpose of the visit to Ericka Tillis, Administrator/Licensee.. LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor areas. Centrally stored medications were locked in medication room. Smoke detectors and carbon monoxide detectors were observed and in working condition. Fire extinguishers were observed to be full and last serviced on 10/30/2024. Temperature in the facility was measured at 82. degrees Fahrenheit at 4:00 PM. Water temperature is 148 degrees Fahrenheit at 11:11 AM. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction. One week of nonperishable and 2 days of perishable food supplies were available. 3 A- and 2 B-type citations issued. Continued on LIC 809-C Continued from LIC 809 Administrator will provide the following documents by 10/1/2024: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 24, 2024

Allegation investigated: Staff did not ensure they were not over capacity Staff are commingling residents Staff did not prevent resident from wandering from the facility Staff are not providing adequate food service to residents

On 09/10/2024 at 11:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Administrator Ericka Tillis. On the allegations: On the allegation Staff did not ensure they were not over capacity and Staff are commingling residents. While at the facility on 5/16/24, LPA observed 4 staff members, and 9 seniors at the facility. Licensee stated that 6 were residents and were 3 visitors who are from her other home at 3770 Suter Street Oakland, 94619. On 9/10/24 LPA observed 9 seniors 6 were residents and were 3 visitors. On the allegation On the allegation Staff did not prevent resident from wandering from the facility. R1 went missing from the facility on 5/1424. R1 was found by the police and returned to the facility. Continued on LIC 9099C... Substantiated ...Continued from 9099A On the allegation Resident fell sustaining injuries resulting in death due to staff neglect. The incident happened in 2018, and the facility no longer has the documentation for this resident. S1 stated that they are only required to keep resident records for three years after a resident passed, so they no longer have R2 documents. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. ...Continued from 9099 On the allegation Staff are not providing adequate food service to residents. It was observed that there was a potato that had been eaten by a rodent in the kitchen. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited. Exit interview conducted. A copy appeal rights, and this report providedthe state’s words, verbatim · CDSS document, Sep 10, 2024 · control 15-AS-20240514153218

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(j) · Plan of correction due date: Sep 17, 2024

The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by R1 AWOLing from the facility on 5/14/24 and no devices were in place at tht time.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: The Licensee agrees to review the regulation and a letter of self certification to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(9) · Plan of correction due date: Sep 17, 2024

(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.This requirement is not met as evidenced by It was observed that there was a potato that had been eaten by a rodent in the kitchen.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: The Licensee argees to clean out the residents kitchen, and reorganize to protect saftey in food storage. Proof of correction will be sent to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Sep 11, 2024

A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time... This requirement is not met as evidenced by… LPA observed 6 residents, and 3 visiting residents at the care facility being cared for.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: The Facility agrees to relocate the additional residents from the facility. Proof of correction will be sent to CCLD by POC date.

Type of visit: Case Management - Incident

While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20240514153218) on 09/10/2024, LPA observed the following: Chemical cleaner left out in the bathroom A rope that was tied a door closed in the residents living room The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Sep 17, 2024

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement is not met as evidenced by… 405 chemical cleaner left out in upstairs bathroom.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: POC cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(l)(2) · Plan of correction due date: Sep 17, 2024

the licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement was not met as evidenced by a rope tying the door in the residents living room.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: POC cleared during visit.

Type of visit: Case Management - Health Checks

On 05/16/24 at 9:30AM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted an unannounced Health and Safety check due to the department receiving a priority 1 complaint. During the health and safety check, LPA observed a total of 4 staff members and 6 residents at the facility and 3 visitors. LPA toured facility with Licensee, including but not limited to bedrooms, kitchen, dining rooms, bathroom, and common areas. LPA observed residents comfortable in their surroundings, eating their breakfast meals and relaxing in common area. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 16, 2024