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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600558
Report Date: 08/22/2024
Date Signed: 08/22/2024 07:07:14 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/22/2024 07:07 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HERITAGE INNFACILITY NUMBER:
415600558
ADMINISTRATOR:EISEMAN, THOMASFACILITY TYPE:
740
ADDRESS:835 JEFFERSON COURTTELEPHONE:
(650) 348-5585
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:12CENSUS: 8DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rose Padolina, Tom and Katie EisemanTIME COMPLETED:
07:15 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 8 client bedrooms, 5 bathrooms, kitchen, living, and dining rooms. There is a fenced backyard and detached 2 car garage, used for storage. Washer and dryer are located near kitchen. No accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars, nonskid flooring material, hand washing reminder signs, and liquid soap. Hot water temperature is tested at 113 degrees in rear bathroom. First-aid kit is inspected and complete. There are 3 staff present. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, and first-aid training is checked. Katie Eiseman is a certified RCFE administrator (x 1/25) that oversees facility operations. Some client files are reviewed.

Per staff, clients #1 and #2 tested positive for COVID. COVID was not reported as required to CCLD, nor San Mateo County Public Health Department. There is no record of when clients were COVID tested. There are no N95 respirators maintained, and only a handful of KN95 masks are available, per staff. Roomwhere COVID clients reside are not identified with appropriate COVID signage nor are there PPE carts outside of rooms. There are 3 staff on site; none are wearing N95 or KN95 masks. There are only 3 small bottles of hand sanitizer on site--all with an inch or less of product in the bottom of bottles.
There is an ample supply of isolation gowns in the garage storeroom and boxes of gloves are stored in kitchen and clients' rooms.

Deficiencies of the California Code of Regulations, Title 22, are cited on following pages.

The following updated form is requested to be submitted to CCLD BY 8/29/24:
• LIC 610 Emergency Disaster Plan (9 pages, signed and dated)
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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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Document Has Been Signed on 08/22/2024 07:07 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: HERITAGE INN
FACILITY NUMBER: 415600558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
CCR
87464(f)(6)

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BASIC SERVICES
Basic services shall at a minimum include:
Arrangements to meet health needs.... as specified in Section 87465, Incidental Medical and Dental Care Services.
This requirement was not met, as licensee failed to ensure an adequate supply of personal protective equipment
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During LPA's visit, administrator arrived with PPE--box of 16.9 oz. bottles of hand sanitizers, 5 N95 respirators, KN95 masks, isolation gowns.
Additional supply of N95 respirators must be maintained.
Plan/proof of correction to be sent to CCLD BY DUE DATE
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(PPE)--N95 masks--is maintained to ensure the safety of staff and residents when COVID infections are present in facility. This poses an immediate health, safety or personal rights risk to clients in care.
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Type A
08/23/2024
Section Cited
CCR87211(a)

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REPORTING REQUIREMENTS
A written report shall be submitted to the licensing agency... within 7 days of the occurrence of any incident which threatens the welfare, safety or health of any resident... report shall include the resident's name, age, sex and date of admission; date and nature of event;
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Copy of COVID Incident Report for client #1 is given to LPA today.
Plan/proof of correction to be submitted to CCLD BY DUE DATE, and shall include written reports of COVID, including staff and client who tested postive during LPA's visit.
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attending physician's name, findings, and treatment... This requirement was not met, as licensee failed to submit written report of 2 COVID clients to CCLD AND County Public Health Dept. This posed an immediate health, safety or personal rights risk to clients in care.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2024 07:07 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: HERITAGE INN
FACILITY NUMBER: 415600558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
CCR
87470(b)(2)(C)

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INFECTION CONTROL REQRMENTS
The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter.
This requirement was not met, as staff are observed in facility wearing surgical
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Plan/proof of correction to be submitted to CCLD BY DUE DATE.
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 masks only, even when assisting client #1 in hallway, who was identified as COVID positive. Licensee failed to ensure that caregivers in direct contact with COVID clients are trained in proper use of PPE , which poses an immediate health, safety or personal rights risk to clients in care.
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Type A
08/23/2024
Section Cited
CCR87355(e)(1)

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, obtain a CA clearance or a criminal record exemption as required by the Department.
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Staff CC shall not have direct contact with clients unless and until criminal record clearance is associated to facility.
Civil penalty of $500 is assessed.
Proof of correction to be submitted to CCLD BY DUE DATE.
Failure to comply may result in civil penalty assessment.
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This requirement is not met, as staff CC started in May & does not have criminal record clearance. Licensee failed to ensure that staff with direct client contact maintain criminal record clearance and assocation with facility, which poses an immediate health, safety, or personal rights risk to clients in care.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2024 07:07 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: HERITAGE INN
FACILITY NUMBER: 415600558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited
CCR
87555(b)(26)

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GENERAL FOOD SERVICE
Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met, as there are only 5 cans of fruit maintained for 7-day
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Proof/plan of correction to be sent to CCLD BY DUE DATE
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non-perishable supply. There are no canned vegetables nor protein maintained. Licensee failed to ensure an adequate 7-day supply of canned foods, which poses a potential health and safety risk to clients in care.
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Type B
08/29/2024
Section Cited
CCR87411(c)(1)

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PERSONNEL REQUIREMENTS--GENL
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement was not met, as 2 out of 6 staff do not have current 1st aid training. Licensee failed to ensure that staff who
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Proof of current first-aid training for staff DJS and JLC will be sent to CCLD BY DUE DATE
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provide client care have current 1st aid training, which poses a potential health, safety or personal rights risk to clients in care.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/22/2024 07:07 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: HERITAGE INN
FACILITY NUMBER: 415600558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
HSC
1569.311

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HEALTH AND SAFETY CODE
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8. This requirement is not met, as there is no carbon monoxide detector in facility. Licensee
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Carbon monoxide detector will be installed and operable, and proof/plan of correction to be sent to CCLD BY DUE DATE.
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failed to ensure that carbon monoxide detector is maintained in facility, which poses an immediate health and safety risk to clients in care.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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