415600558-2-1-2023-14-AS-KHOS-CPAP62-20230222100138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600558
Report Date: 02/01/2023
Date Signed: 02/01/2023 05:14:56 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220826142550

FACILITY NAME:	HERITAGE INN		FACILITY NUMBER:	415600558
ADMINISTRATOR:	DELA CRUZ, ANNIE		FACILITY TYPE:	740
ADDRESS:	835 JEFFERSON COURT		TELEPHONE:	(650) 348-5585
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	12	CENSUS: 10	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	04:10 PM
MET WITH:	Administrator, Annie Dela Cruz		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Staff did not notice a change in resident's condition

INVESTIGATION FINDINGS:

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On 2/1/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220826142550. LPA Han met with caregiver, Mei Murasaki and administrator, Annie Dela Cruz arrived shortly thereafter. LPA explained the purpose of the visit.

Regarding to allegation of- staff did not notice a change in resident's condition, the reporting party stated that resident #1 (R1) developed a skin condition on the right great toe and the facility did not report it.

As part of the investigation, LPA interviewed R1's responsible party who stated that the facility did not notified the responsible party of R1's change of condition on the right great toe and the responsible party was notified by R1's provider.

LPA Jeung interviewed R1's provider who stated he/she observed R1 developed a skin condition on the right great toe and it was not reported by the facility prior to the observation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20220826142550

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 02/01/2023

NARRATIVE

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LPA interviewed staff #1 (S1) who stated R1's great toe skin condition is being taking care of by a visiting nurse from the home health agency and S1 was unsure if this change of condition was reported to R1's provider, responsible party and CCL.

LPA interviewed facility's co-administrator and administrator/licensee who was not able to confirm that the above change of condition was reported or not.

In addition, the facility was not able to provide any documentation to proof that the above change of condition was reported to the provider, the responsible party and CCL.

Furthermore, facility was not able to provide a copy of R1's appraisal/needs and service plan. This observation will be cited on a LIC 809 and LIC809D under case management as the facility did not updated R1's appraisal/ needs and service plan to note the significant changes and to keep the appraisal accurate.

Based on observation, interviews and record reviews during the course of the investigation, this allegation is deemed to be substantiated.

After the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the administrator.

Appeal Rights and a copy of this report are provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20220826142550

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A 02/02/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.	1 2 3 4 5 6 7	The administrator/licensee will review the regulation and provide a signed statement of acknowledgment after the review. The administrator/licensee will provide in-services to staff on reporting requirement.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by R1 sustained a change of condition on the right great toe and the facility did not report it which posed an immediately health risk for resident in care.	8 9 10 11 12 13 14	The administrator/licensee will provide a copy of the signed statement and a copy of the in-service record to CCL by 2/2/2023.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 5 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2022 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20220826142550

FACILITY NAME:	HERITAGE INN		FACILITY NUMBER:	415600558
ADMINISTRATOR:	DELA CRUZ, ANNIE		FACILITY TYPE:	740
ADDRESS:	835 JEFFERSON COURT		TELEPHONE:	(650) 348-5585
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	12	CENSUS: 10	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	04:10 PM
MET WITH:	Administrator, Annie Dela Cruz		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Staff did not assist resident with incontinence needs
Staff did not ensure resident was wearing clean clothing

INVESTIGATION FINDINGS:

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On 2/1/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220826142550. LPA Han met with caregiver, Mei Murasaki and administrator, Annie Dela Cruz arrived shortly thereafter. LPA explained the purpose of the visit.

Regarding to allegation of- staff did not assist resident with incontinence need, the reporting party stated that resident #1 (R1) was in soiled diaper but not sure for how long.

As part of the investigation, LPA interviewed facility staff and administrator who denied the allegation. Facility staff stated R1 is incontinent and staff checked and changed R1 on a regular basis. However, it could be possible that R1 had a bowel movement and not being cleaned right away as staff was assisting other residents.

According to R1's responsible party, R1 has been residing at the facility for years and a family member visits R1 on a daily basis and they observed R1 to be cleaned and comfortable. They have not noticed any foul odor on R1 during their daily visits.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 14-AS-20220826142550

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 02/01/2023

NARRATIVE

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During LPA 10-day unannounced visit, LPA observed R1 and other 6 residents to be cleaned, and comfortable.

Based on observation and interviews during the course of the investigation, this allegation is deemed to be unsubstantiated.

Regarding to allegation of - staff did not ensure resident was wearing clean clothing, the reporting party stated that R1's blouse was torn, and soiled with food.

During LPA 10-day unannounced visit, LPA observed R1 and 6 residents to be cleaned, well dressed and comfortable.

LPA interviewed R1's responsible party who stated that they have not observed R1 wearing torn and soiled clothes. In addition, the responsible party stated that during their daily visit, they observed R1 to be comfortable and cleaned.

Based on observation and interviews during the course of the investigation, this allegation is deemed to be unsubstantiated.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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