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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804084
Report Date: 08/31/2026
Date Signed: 08/31/2026 03:58:01 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/31/2026 03:58 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: 5DATE:
08/31/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Leonardo Lalim, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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At approximately 10:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Leonardo Lalim, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care, all of whom were present during today's inspection. Facility has a Dementia Care Plan, a Hospice waiver for six (6), is approved for all non-ambulatory residents, and is vendored with the North Bay Regional Center (NBRC).


At approximately 10:30 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. LPA observed egress devices activated on all facility doors. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There are shaded seating areas in both the front- and backyards with outdoor space for activities. LPA observed residents resting in their rooms or watching TV in the common area. Facility has internet service and during inspection Administrator purchased an internet access device designated for resident use to bring the facility into compliance with regulation. The telephone was tested and was operational during inspection. Facility has a generator to supply power in an emergency. Emergency lighting devices were present. First aid kit was present. All employees are background checked and cleared to work in the facility.

Continued on LIC809-C...
Bethany Moellers
Julie Florio
DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/31/2026
NARRATIVE
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Continued from LIC809...

No pools/bodies of water are on the premises. Facility conducts emergency drills every 3 months with the most recent drill conducted 06/2026. Facility's emergency disaster plan was observed posted in the facility and was last updated 01/2026. Fire extinguishers were observed fully charged and were last inspected 09/2025.

During inspection, LPA observed Resident 1 (R1) in bed with legs and feet floated off of the bed with padding and air filled booties and a sheet tented over the lower extremities. LPA observed R1 with a reddish dime sized area with a scab on R1's left heel. Administrator stated that R1 had been on home health for the care of the heel wound which is reflected as a stage 3 pressure injury in R1's physician's reports dated 10/18/2024, 04/16/2025, and 05/18/2025. R1's most recent physician's report dated 03/18/2026 does not mention the pressure injury. LPA also observed progress notes from the home health agency providing care for R1's wound dated 08/06/2024, 06/30/2025, and 08/19/2026. Administrator states that home health was discontinued after 08/19/2026 visit. Administrator states they observed redness and a discoloration on R1's left calf area approximately two days ago. LPA observed a bandage placed on R1's left calf area which fell off when administrator lifted R1's leg for observation. LPA observed a red area approximately 4 inches in diameter and a black and blue area in the middle approximately 2 inches in diameter under that bandage on R1's left calf area, (see LIC809D). LPA discussed prohibited health conditions with administrator and provided administrator a copy of regulation 87631: Healing Wounds. LPA requested Administrator have the wound evaluated by a medical professional, staged, and obtain any orders for care as well as confirmation of R1's ambulatory status. Administrator conveyed understanding and agreed to comply. Administrator scheduled an appointment with R1's podietrist on 09/02/2026 but after discussion during today's visit contacted EMS to send R1 to the hospital for evaluation today.

At approximately 11:15 AM, LPA followed up on an incident report received by the Department on 08/26/2026 regarding an incident that occurred on 08/22/2026 involving Resident 2 (R2). LPA reviewed R2's physician's reports dated 08/17/2026 and 08/28/2026 and appraisal needs a services plan dated 06/01/2026.

Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
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: 08/31/2026
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Continued from LIC809C...

LPA also interviewed Administrator who stated that the responsible party and home health nurse were both aware of the situation when a small amount of blood was observed in R2's catheter bag and advised facility to continue monitoring it and to send R2 to the ER if signs and symptoms worsened, which facility did the next morning upon observing increased blood in the catheter bag. Additionally, R2's 08/17/2026 physician's report indicates a bedridden status. LPA requested the facility have R2 re-evaluated to confirm whether R2 in bedridden. Administrator understands that the facility is not approved for bedridden residents and agrees to work with the resident and their family on placement in another facility if a bedridden status is confirmed.

At approximately 12:00 PM, LPA reviewed 4 of 5 resident files. All resident files contained the required documentation. Reappraisals were conducted within the last 12 months. Documentation of physician visits within the last 12 months were present.

At approximately 2:30, LPA reviewed 2 of 4 staff files which were observed to contain all of the required documentation including current first aid certificates and training. Both files also contained current CPR certificates.

LPA reviewed medications and medication logs which were inspected and observed stored and maintained in compliance with regulation. Facility does not manage P&I cash resources.



Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the deficiencies by the plan of correction date and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator whose signature on form confirms receipt of documents. Appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2026 03:58 PM - It Cannot Be Edited


Created By: Julie Florio On 08/31/2026 at 03:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HEART TO HEART PROVIDER, LLC
FACILITY NUMBER: 286804084

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2026
Section Cited
CCR
87631(a)(3)(A)

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Healing Wounds 87631(a)(3)(A) The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional.

This requirement is not met as evidenced by:
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Licensee immediately contacted emergency medical services (EMS) to have R1 sent to the hospital for evaluation of their wounds. Licensee to submit a self-certification that they have reviewed the regulation with all staff to CCL by POC due date 09/01/2026.
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Based on observation, the Licensee did not comply with the section cited above in ensuring that R1 is receiving the required medical care for observed wounds on their left heel and left calf area which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2026


LIC809 (FAS) - (06/04)
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