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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201151
Report Date: 04/10/2024
Date Signed: 04/10/2024 01:30:55 PM

Document Has Been Signed on 04/10/2024 01:30 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HERITAGE HOME ARFFACILITY NUMBER:
079201151
ADMINISTRATOR/
DIRECTOR:		BONIFACIO, ALFREDO JRFACILITY TYPE:
735
ADDRESS:14 RED BARN CT.TELEPHONE:
(925) 679-0845
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 5DATE:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:48 AM
MET WITH:Ronald Hipa CargiverTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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On 04/10/2024 at 9:48AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with caregiver Ronald Hipa and explained the purpose of the visit. Licensee Alfredo Bonifacio arrived at 10:38 AM. The Administrator currently holds a certificate (#6035593735) expires 03/06/2025. Facility has census of 5. LPA observed two (2) clients. The facility’s fire clearance was approved for six (6) ambulatory residents.

LPA toured the facility with Caregiver Chito Ates including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) bedrooms and four (4) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the clients’ shared bathroom was measured at 106.2 degrees Fahrenheit. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/14/2023. Emergency Disaster Plan was last posted on 01/17/2024. First aid kit was observed to be complete. Fire drill was last conducted on 03/05/2024.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HERITAGE HOME ARF
FACILITY NUMBER: 079201151
VISIT DATE: 04/10/2024
NARRATIVE
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Continued from LIC809.

Four (4) staff records were reviewed. LPA reviewed all five (5) clients records, and they were current and complete. LPA reviewed samples of medication.


LPA requested the following documents to be submitted to CCLD by 04/18/2024.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 610E Emergency Disaster Plan
· Liability Insurance

LPA observed the following deficiencies:
  • AT 9:45 AM LPA observed no signal system in clients rooms on second floor.
  • AT 10:31 LPA observed unlocked cabinet with disinfectants in the kitchen.



Deficiency is 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 the appeal rights, LIC421BG, and the report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/10/2024 01:30 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 04/10/2024 at 12:49 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: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to 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 in having disinfectants in an unlocked kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Caregiver immediately locked the cabinet with disinfectants during visit. Deficiency cleared.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/10/2024 01:30 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 04/10/2024 at 12:58 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: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(f)(2)
85088 Fixtures, Furniture, Equipment and Supplies
(f) Facilities shall meet the following signal system requirements:
(2) Facilities having more than one wing, floor or building shall be allowed to have a separate signal system in each component provided that each such system meets the criteria specified in (1)(A) through (C) above.

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 in not having an sigal system for clients on second floor which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Adminstrator agreed to purchase signal system and provide reciept via email to CCLD 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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