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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600559
Report Date: 09/27/2024
Date Signed: 09/27/2024 10:46:52 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
07/17/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240717101429
FACILITY NAME:HERITAGE PLACEFACILITY NUMBER:
415600559
ADMINISTRATOR:GRATUITO, VILLAROSEFACILITY TYPE:
740
ADDRESS:152 24TH AVENUETELEPHONE:
(650) 573-9472
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:12CENSUS: 7DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee - Katie EisemanTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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- Staff did not perform a proper assessment of resident
- Staff did not meet the needs of the resident
INVESTIGATION FINDINGS:
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On 09/27/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with licensee Katie Eiseman and explained the purpose of today's visit.

During the investigation LPA conducted interviews and reviewed documentation pertinent to the investigation. Per interviews conducted it was found that the licensee/administrator Katie Eiseman did not conduct an in person assessment of the resident prior to him/her being accepted into the faciilty. The facility relied on the statements and documentation from the skilled nursing facility (SNF) he/she were coming from as their assessment. It was only discussed via telephone/facetime. Part of what was not assessed in person was the funcional capabilities of the resident and ability of self care. The resident had an unwillingness for self care which caused decline in his/her health. The resident was respoinsible for their own care and decisions. Unknown to the facility was the insurance issues of the resident and that it had lapsed without the facilities knowledge which caused issues with medications and home health.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

Report is reviewed with licensee and a copy is provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 14-AS-20240717101429
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PLACE
FACILITY NUMBER: 415600559
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2024
Section Cited
CCR
87457(c)
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87457(c) Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This regulation has not been met as evidenced by:
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The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 9/28/2024. The administrator will provide a copy of the completed preadmission appraisals to CCL by 9/25/2024.
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Based on interviews conducted, the facility did not perform a proper assessment prior to admission of the resident in the facility. The facility relied solely on the information provided by the skilled nursing facility instead of doing their own pre-admission appraisal of the resident
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Type A
09/28/2024
Section Cited
CCR
87459(a)(4)
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87459(a)(4) Functional Capabilities - The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to: (4) Transferring, including the need for assistance in moving in and out of a bed or chair. This regulation has not been met as evidenced by:
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The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 9/28/2024. The administrator will provide a copy of the completed preadmission appraisals to CCL by 9/25/2024.
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Based on interviews conducted, the facility did not assess the functional capabilities of the incoming resident and relied solely on the assessment of the skilled nursing facility in order to accurately assess the functional capabilities of the resident.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
07/17/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240717101429

FACILITY NAME:HERITAGE PLACEFACILITY NUMBER:
415600559
ADMINISTRATOR:GRATUITO, VILLAROSEFACILITY TYPE:
740
ADDRESS:152 24TH AVENUETELEPHONE:
(650) 573-9472
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:12CENSUS: 7DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee - Katie EisemanTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff did not re-order residents medications timely causing the resident to run out of medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/27/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with licensee Katie Eiseman and explained the purpose of today's visit.

During the investigation LPA conducted interviews and reviewed documentation pertinent to the investigation. Per interviews conducted with the licensee/administrator, the facility was not aware of the residents insurance being lapsed, which is why the medications of the resident was not delivered to the facility after two weeks of the resident being in the facility. The facility sent the resident to the hospital so he/she could receive the medications needed. The facility was unaware of any issues regarding the insurance of the resident and was expecting the medication to be sent to the facility as part of the resident being discharged from a skilled nursing facility (SNF) to this facility as it was arranged for the resident by the SNF. The resident was their own responsible party and did not inform the facility of any insurance issues. This allegation is unsubstantiated.

The resident was supposed to receive medications timely and home health visits as part of his/her care plan when leaving the SNF. After two weeks there were no visits from home health took place and the medications as well ran out. As a result of precaution, the facility sent the resident to the hospital so he/she can receive the medications needed and have the resident checked. As a result of the hospital visit the facility found out the insurance of the resident had lapsed for some reason unknown to the facility. The facility was able to re-establish home health for the resident and medications. These allegations are substantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Report is reviewed with licensee and a copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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 3