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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201151
Report Date: 04/17/2023
Date Signed: 04/17/2023 03:00:24 PM

Document Has Been Signed on 04/17/2023 03:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HERITAGE HOME ARFFACILITY NUMBER:
079201151
ADMINISTRATOR:BONIFACIO, ALFREDO JRFACILITY TYPE:
735
ADDRESS:14 RED BARN CT.TELEPHONE:
(925) 679-0845
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 5DATE:
04/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Alfredo Bonifacio Jr., Administrator TIME COMPLETED:
03:30 PM
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On this day 4/17/2023 at around 12:30PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced at the facility to conduct annual required inspection. LPA was met with Administrator Alfredo Bonifacio Jr. LPA informed Administrator the purpose of the visit.

LPA toured the entire premises indoors and outdoors. The facility has 7 bedrooms including master bedroom, 4 bathrooms including master bathroom, two story house per facility sketch. 6 bedrooms are designated for clients. LPA observed 2 fire extinguisher which was in the kitchen and second floor of the home, service date of Sept.15,2022. Smoke detectors and carbon monoxide detectors were observed operational. The facility received a fire clearance dated 03/25/2022 with an approval for capacity of 6 ambulatory clients only.

Facility has sufficient supply of perishable and non-perishable foods. There are 4 staff working during the visit and both are fingerprint cleared. Bathrooms were observed with grab bars and nonskid mats.

LPA reviewed 3 clients and 3 staff files and interviewed 2 clients and 3 staff. Facility has wired carbon monoxide and smoke detector that were observed functional. Facility has a current liability insurance.

LPA observed the following:
At around 11:47AM, LPA observed two canned good expired on 11/2022.

Deficiencies are being cited today in violation of California Code of Regulations and follows on 809D. Failure to submit proof of corrections (POC's) along with LIC9098 by plan of correction due dates may result in civil penalty.

Exit interview was conducted with Administrator and Appeal Rights was provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
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 04/17/2023 03:00 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/17/2023 at 02:30 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 HOME ARF
FACILITY NUMBER: 079201151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(1)
Food Services
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients….

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 which LPA found two expired canned goods inside the facility pantry, which poses an potential health risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Staff discarded the expired item.
Administrator to have all the food supplies checked and conduct in-service training. Proof to be submitted by 4/28/2023.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023


LIC809 (FAS) - (06/04)
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