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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600558
Report Date: 02/01/2023
Date Signed: 02/01/2023 05:20:37 PM


Document Has Been Signed on 02/01/2023 05:20 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HERITAGE INNFACILITY NUMBER:
415600558
ADMINISTRATOR:DELA CRUZ, ANNIEFACILITY TYPE:
740
ADDRESS:835 JEFFERSON COURTTELEPHONE:
(650) 348-5585
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:12CENSUS: 10DATE:
02/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Administrator, Annie Dela CruzTIME COMPLETED:
05:30 PM
NARRATIVE
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On 2/1/2023, Licensing Program Analysts (LPA) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220826142550. LPAs met with caregiver, Mei Murasaki and administrator, Annie Dela Cruz arrived shortly thereafter. LPA explained the purpose of the visit.

During the course of the investigation, the allegation of resident #1 (R1) sustained a skin condition on the right great toe and it was not reported, the facility was not able to provide a copy of R1's appraisal/needs and service plan (LIC 625) to reflect R1's current health conditions and plan of care.

According to the administrator/licensee, the facility did not complete an appraisal/needs and service plan (LIC625) for R1's change of health condition.

Based on the complaint investigation, the facility failed to complete a LIC 625 for R1's change of health condition.

Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with administrator.

A copy is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
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 02/01/2023 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: HERITAGE INN
FACILITY NUMBER: 415600558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/08/2023
Section Cited

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87463 Reappraisals(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...
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The administrator will review the regulation and submit a written/signed statement to CCL of acknowledging the review.
The administrator will complete an appraisal/needs and service plan for R1 and all the residents
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this requirement is not met as R1 developed a skin condition on the right great toe and the facility did not complete a LIC625 (Appraisal/needs and service plan) which posed a potential risk for resident in care.
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to reflect their current plan of care. The administrator will provide in-service to staff pertaining to this deficiency. The administrator will provide a copy of the written acknowledgment, a copy of current residents appraisal and service plans and a copy of the in-service record, a copy of the signed acknowledging the review of the regulation and a copy of resident's appraisal/service plans to CCL by 2/8/2023.

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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
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