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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600559
Report Date: 07/18/2024
Date Signed: 07/18/2024 04:03:07 PM


Document Has Been Signed on 07/18/2024 04:03 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 PLACEFACILITY NUMBER:
415600559
ADMINISTRATOR:GRATUITO, VILLAROSEFACILITY TYPE:
740
ADDRESS:152 24TH AVENUETELEPHONE:
(650) 573-9472
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:12CENSUS: 7DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator - Villarose GratuitoTIME COMPLETED:
04:00 PM
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On 07/18/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with administrator Villarose Gratuito then later the co-licensee Thomas Eisman arrived and LPA met with him as well.

LPA was allowed entry into the facility. This is a single level facility approved all residents to be non-amblatory and 6 hospice residents. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer adjacent to the facility stove. Medications are observed to be locked in a cabinet adjacent to the refrigerator. Perishable and non-perishable food items are observed as in place. There are additional refrigerator and freezer in the garage area which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers in place inspected 06/21/2023, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. The facility has fire sprinkler system through out the facility. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 01/08/202 which can pose a potential health and safety risks for residents and staff in care. Per administrator they have conducted additional drills but the documentation does not reflect this from happening. Water temperature was measured at 130F in a common resident bathroom in the hallway connecting to resident rooms. This temperature poses an immediate health and safety risk to residents in care.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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 PLACE
FACILITY NUMBER: 415600559
VISIT DATE: 07/18/2024
NARRATIVE
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LPA observed rooms numerous resident rooms and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. All resident rooms are equipped with half baths. Resident linen supplies are observed as in place. Cleaning supplies are also observed as locked inaccessible to residents in care. There is a staff room connected to the living room. Facility does not handle resident monies.

The following updated forms are requested to be submitted to CCLD by 07/25/2024:

• Copy of updated Administrator Certificates
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property

Citation issued on this day on the attached LIC809D. Report is reviewed with the administrator and a copy is provided on this day.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/18/2024 04:03 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 PLACE
FACILITY NUMBER: 415600559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2024
Section Cited
CCR
87303(e)(2)

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87303(e)(2) Maintenance and Operation (e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This regulation has not been met as evidenced by:
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Facility shall develop a written plan on how to address this regulation and keep a record showing that the water temperature delivered is within regulatory standards at all times.
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Based on physical plant tour and water temperature taken in common hallway bathroom, the water temperature was measured at 130F which poses an immediate health and safety risk to residents in care.
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Type B
07/25/2024
Section Cited
HSC1569.695(c)

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§1569.695 Emergency Plans(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This health and safety code has not been met as evidenced by:
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Facility shall create a written plan on how to meet this health and safety code section at all times and maintaining the record of such drills accurately.
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Based on documentation reviewed, LPA observed the disaster drill/fire drill log has not been updated since 01/08/2020. Per disucssion with the administrator they have conducted such drills but the docuementation has not been updated. This can pose a potential health and safety risk to residents and staff 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) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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