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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600561
Report Date: 08/21/2019
Date Signed: 08/22/2019 07:52:12 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HERITAGE PARKFACILITY NUMBER:
415600561
ADMINISTRATOR:HOLLOWAY, MERCEDESFACILITY TYPE:
740
ADDRESS:843 JEFFERSON COURTTELEPHONE:
(650) 344-1855
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 5DATE:
08/21/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mercedes Holloway AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to complete the Required 1 Year inspection. LPA met with Mercedes Holloway Administrator. LPA toured the facility inside and out.

Hallways and passages ways and fire exits were clear of obstructions. The facility has a central alarm system and is connected to the fire department. Smoke Detectors in the bedrooms and Carbon monoxide detectors in the hallways were tested and functioning properly. Fire extinguishers were last serviced on 4/8/2019.

Bathrooms are equipped with grab bars and non-skid mats. Hygiene supplies and toiletries are available to the residents. Facility is equipped with lamps and comfortable lighting. Hot water temperature was tested in the hall bathroom and measured at 113 degrees Fahrenheit.

LPA observed 2 days worth of perishables and 7 days worth of nonperishable food products for the residents. LPA observed fresh fruit of watermelon available for the residents.

Knives and sharp objects were locked and in a drawer in the kitchen. Toxins and cleaning supplies are locked in cabinets in the laundry room area. Medications are stored in a locked closet in the hallway. These items were inaccessible to the residents. Centrally Stored Medication Record was reviewed. First Aid Kit was complete.

At 2:30pm LPA reviewed 5 resident and 4 staff files.

Resident records all contain admission agreements, current assessments and physician's report signed by a physician.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019
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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: HERITAGE PARK
FACILITY NUMBER: 415600561
VISIT DATE: 08/21/2019
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Administrator Mercedes Halloway certificate is current and expires on 6/15/2020.

Facility staff all have criminal record clearance and are associated to work at the facility. Facility staff all have current first aid certificates. Facility staff annual training in process for 2019.

Administrator will submit the following updated forms to Community Care Licensing by 9/3/2019:

LIC308- Designation of Facility Responsibility
LIC610E Emergency Disaster Plan
Updated General Liability Insurance Certificate
Updated Lease Agreement

Advisory notes provided to Administrator regarding Emergency Drills and Appraisal Needs and Services Plan.

No deficiencies cited today per the California Code of Regulation Title 22.

This report was reviewed with Mercedes Halloway Administrator and a copy of this report provided.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019
LIC809 (FAS) - (06/04)
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