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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200506
Report Date: 01/25/2023
Date Signed: 01/25/2023 12:51:34 PM

Document Has Been Signed on 01/25/2023 12:51 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HERITAGE HAVENFACILITY NUMBER:
019200506
ADMINISTRATOR:FERDINAND GUTIERREZFACILITY TYPE:
740
ADDRESS:389 JUANA AVENUETELEPHONE:
(510) 357-1300
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 27CENSUS: 21DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Laila Deguzman, Caregiver TIME COMPLETED:
01:15 PM
NARRATIVE
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On 1/25/2023 at 11:18 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Caregiver, Laila Deguzman and explained the purpose of the visit. Caregiver spoke with the Administrator on the phone. Administrator was unable to join the visit and let Laila sign the documents.

During the Infection Control Inspection, LPA toured facility with Laila including but not limited to front entrance, hand washing stations, bedrooms, common areas, kitchen, and backyard. Visitors policy is posted on the front entrance. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily.
Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Smoke and carbon monoxide detectors were observed and are connected to the sprinkler system. First Aid kit was complete. LPA observed facility passages inside and out free of obstruction.


Report continues on 809 C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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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Document Has Been Signed on 01/25/2023 12:51 PM - It Cannot Be Edited


Created By: Paris Watson On 01/25/2023 at 12:15 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HERITAGE HAVEN
FACILITY NUMBER: 019200506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having a minimum of 7-day non-perishable and 2-day perishable foods available for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
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Administartor will buy more non perishable and perishable foods and send photographic proof by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Paris Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023


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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HERITAGE HAVEN
FACILITY NUMBER: 019200506
VISIT DATE: 01/25/2023
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The following deficiency was observed during inspection:

-At approximately 11:40 AM LPA observed that the facility did not have a sufficient 2 day perishable and 7 day non-perishable food supply.


The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties


Exit interview conducted and a copy of this report provided along with Appeal rights
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC809 (FAS) - (06/04)
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