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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600561
Report Date: 05/09/2022
Date Signed: 05/09/2022 12:06:43 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/02/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220502141852
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: 6DATE:
05/09/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Mercy Holloway and Annie De La CruzTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared adult working at facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Jeung met with administrators and inspected garage behind RCFE next door at 835 Jefferson Court-- Heritage Inn #415600558--which is also operated by Heritage Residential Care, Inc. According to administrators, there is no one working or residing on premises who does not have criminal record clearance. Two car garage is used to store furnishings, food and other items. There is no evidence of occupancy in the garage.

This complaint alleging that someone without criminal record clearance has been investigated by the Community Care Licensing Division of the CA Department of Social Services, and determined to be unfounded. This means that the allegation could not have happened and/or is without a reasonable basis.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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