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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600561
Report Date: 08/26/2024
Date Signed: 08/26/2024 05:28:26 PM

Document Has Been Signed on 08/26/2024 05:28 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 PARKFACILITY NUMBER:
415600561
ADMINISTRATOR/
DIRECTOR:		HOLLOWAY, MERCEDESFACILITY TYPE:
740
ADDRESS:843 JEFFERSON COURTTELEPHONE:
(650) 344-1855
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 5DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Mercedes HollowayTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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LPA Jeung toured facility and grounds, which includes spacious fenced backyard. There are 6 client bedrooms and a staff room, and 3 full bathrooms. There are no accessible bodies of water or fire safety hazards observed. Sharps are stored appropriately and inaccessible to clients, and a comfortable temperature is maintained. Hot water tank is replaced during LPA's visit, and does not yet produce hot water. Carbon monoxide detector is tested and operable. Food supply and first-aid kit are inspected. Client files are reviewed, and medications are recorded on Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Mercedes Holloway, Tom Eiseman and Katie Eiseman (x 1/25) are certified RCFE administrators that oversee facility operations.

The following information/forms are requested to be sent to CCLD BY 9/9/24:

- LIC 610D Emergency Disaster Plan (page 9, signed and dated)
- Proof of current liability insurance

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed.
See also Technical Advisory Notes--4 pages.
April Cowan
Audrey Jeung
DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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 08/26/2024 05:28 PM - It Cannot Be Edited


Created By: Audrey Jeung On 08/26/2024 at 04:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HERITAGE PARK
FACILITY NUMBER: 415600561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records review, the licensee did not comply with the section cited above in 3 out of 6 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
Health Screenings for Staff #3, #4, #6 are dated more than 6 months prior to employment date.
POC Due Date: 09/09/2024
Plan of Correction
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Health screenings and TB test results for 3 staff will be updated and copies sent to CCLD BY DUE DATE.

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 Cowan
TELEPHONE:
LICENSING EVALUATOR NAME:Audrey Jeung
TELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
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