Community Care Licensing

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) -62-2621 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024

Document Has Been Signed on 02/14/2024 05:19 PM - It Cannot Be Edited

FACILITY NAME: HERITAGE HAVEN	FACILITY NUMBER: 019200506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2024

Type B

Section Cited

CCR

87203

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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above with non-operational smoke detectors, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	Licensee shall replace all smoke detectors with new fully operational smoke detectors.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) -62-2621 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024

Document Has Been Signed on 02/14/2024 05:19 PM - It Cannot Be Edited

FACILITY NAME: HERITAGE HAVEN	FACILITY NUMBER: 019200506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2024

Type B

Section Cited

CCR

87470(a)(2)(A)

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary.  These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material.  This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above throughout the facility, with flooring that is in disrepair: the vinyl and/or linoleum flooring is chipped, the carpeting has holes, dirty, frayed on the edges, and littered with gum and/or other substances stuck to it, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	Licensee shall replace all flooring in disrepair with commercial grade vinyl or linoleum.

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above with a window cracked in room 21, kitchen cabinets and drawers in disrepair, broken garbage disposal in kitchen sink, a broken sink in room #2, which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	Licensee shall replace or repair to full function all items in disrepair within the facility including all listed above and any others not listed above.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) -62-2621 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024

Document Has Been Signed on 02/14/2024 05:19 PM - It Cannot Be Edited

FACILITY NAME: HERITAGE HAVEN	FACILITY NUMBER: 019200506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2024

Type B

Section Cited

CCR

87303(c)

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above the window screens in rooms 2 and 10 in disrepair, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	All window screens must be inspected, repaired, or replaced by the Licensee.

Type B

Section Cited

CCR

87303(e)(6)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above with bathroom #12 sink broken and leaking faucets in Administrator room, Staff room, and Basement, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	All broken plumbing fixtures must be inspected, repaired, or replaced by the Licensee.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) -62-2621 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024

Document Has Been Signed on 02/14/2024 05:19 PM - It Cannot Be Edited

FACILITY NAME: HERITAGE HAVEN	FACILITY NUMBER: 019200506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2024

Type B

Section Cited

CCR

87303(g)(1)

(g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair. Space used to sort soiled linen shall be separate from the clean linen storage and handling area. Except for facilities licensed for fifteen (15) residents or less, the space used to do laundry shall not be part of an area used for storage of anything other than clean linens and/or other supplies normally associated with laundry activities. Steam, odors, lint and objectionable laundry noise shall not reach resident or employee areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above with washer in disrepair, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	Licensee shall replace clothes washer with a commercial washer.

Type B

Section Cited

CCR

87307(d)(2)

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above with second floor patio in disrepair, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	The Licensee shall permanently repair the second-floor patio, including the siding and flashing and a concrete walking surface, and the damage done to the first floor exterior of the building siding and ceiling of the patio cover.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) -62-2621 LICENSING EVALUATOR NAME: James Sampair TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024