415600559-9-8-2022-14-AS-KCHA-CJ3NXC-20220908105054

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600559
Report Date: 09/08/2022
Date Signed: 09/08/2022 10:51:12 AM

Document Has Been Signed on 09/08/2022 10:51 AM - 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 PLACE		FACILITY NUMBER:	415600559
ADMINISTRATOR:	GRATUITO, VILLAROSE		FACILITY TYPE:	740
ADDRESS:	152 24TH AVENUE		TELEPHONE:	(650) 573-9472
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	12	CENSUS: 11	DATE:	09/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator, Villarose Gratuito		TIME COMPLETED:	11:05 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On September 8, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front door. LPA met with a staff member (S1), and Administrator, Villarose Gratuito joined shortly thereafter. LPA explained the purpose of the visit. Administrator was able to provide LPA was screening log documentation for staff, residents and visitors. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are present: entry procedures, and daily monitoring for residents and staff. LPA observed the COVID signage posted throughout the facility. This is a single story with 9 bedrooms (3 shared rooms and 6 private rooms), 4 half-bathrooms, 1 shower room, and 2 full bathrooms. LPA observed all bathrooms in the facility and advised Administrator to throw all bar soaps away and ensure bathrooms are equipped with liquid soap. In addition, LPA did not observe any hand-towels and there were no lids on the trash cans. Hand-washing signage was observed in bathrooms. LPA toured all resident rooms and observed the 3 shared rooms to have beds 6ft apart from each other. LPA toured the kitchen and advised Administrator to switch out hand-towels for paper-towels and disinfectant wipes. LPA observed 2 day perishable and 7 day non-perishable. LPA observed sharps drawer to be unlocked and accessible to residents. LPA toured the garage and observed extra food supply. LPA observed the medications locked an inaccessible to residents. First aid kits was observed to be completed. Washer and dryer in laundry room were in good repair. Cabinet with chemicals was observed to be unlocked and accessible to residents. CONT. to 809C

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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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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 PLACE	FACILITY NUMBER: 415600559
	VISIT DATE: 09/08/2022

NARRATIVE

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Shower room was observed. According to the Administrator, no residents use the shower room. The living room was clear from any tripping hazards. A comfortable temperate at 81 degrees F was maintained. Lighting was sufficient for comfort.

It was found during the visit that S1 was not fingerprint cleared and associated to the facility. According to the Administrator, she sent the fingerprint transfer documents to the Licensee, however the Licensee failed to associate S1 prior to working at the facility. This violation results in a civil penalty of $100 per day x 2 days = $200.00

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator and a copy is provided with appeals rights. Civil Penalty is also assessed and given during the visit.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 09/08/2022 10:51 AM - 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 PLACE	FACILITY NUMBER: 415600559
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance (e) 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, it was found that S1 is fingerprint cleared however, S1 is not associated to the facility. Facility failed to ensure the S1 is associated prior to working which poses an immediate health and safety risk for residents in care.
	POC Due Date: 09/09/2022
	Plan of Correction
1 2 3 4	Facility Administrator to associate S1 by the end of the day or provide LPA with documents to have S1 associated to the facility. S1 will not work at the facility until associated.

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, facility failed to ensure knives and sharps are locked an inaccessible to residents which poses an immediate health and safety risk to residents in care.
	POC Due Date: 09/09/2022
	Plan of Correction
1 2 3 4	Facility administrator will move knives to a locked cabinet and provide LPA with a photo of locked sharps and knives.

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 09/08/2022 10:51 AM - 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 PLACE	FACILITY NUMBER: 415600559
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, facility failed to ensure chemicals and toxins are locked and stored away and inaccessible to residents which poses an immediate health and safety risk to residents in care.
	POC Due Date: 09/09/2022
	Plan of Correction
1 2 3 4	Facility administrator will lock the cabinet with all toxins and chemicals and provide LPA with photos.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 09/08/2022 10:51 AM - 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 PLACE	FACILITY NUMBER: 415600559
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, facility failed to ensure all bathrooms are equipped with liquid soap, paper towels, and a trash can with a covered lid which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/15/2022
	Plan of Correction
1 2 3 4	Facility administrator to place paper towels in the bathrooms, remove all bar soaps. Administrator to request covered trash cans from Licensee and will provide LPA photos.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

Page: 5 of 5