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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600561
Report Date: 06/03/2025
Date Signed: 06/03/2025 04:38:05 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
02/26/2025 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250226131504
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: 3DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Mercedes HollowayTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained multiple injuries while in care

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Based on records reviewed and interviews with staff and witnesses, this allegation is determined to be unsubstantiated. Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.

Former client was admitted in January 2025 and retained private caregivers for about one month, until client began receiving hospice care. He passed away in March 2025. Upon admission, MD ordered that client be rotated in bed every 2 hours to prevent skin breakdown. Client may have had a developing wound--discoloration of skin--upon admission, but information was not consistent. Conflicting information about client's skin condition was documented by medical professionals who provided care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
02/26/2025 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250226131504

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: 3DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Mercedes HollowayTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff sedated resident in care
Staff left residents in soiled diapers for an extended period of time
Staff handled resident in a rough manner
Staff yelled at resident in care
Facility is not kept clean

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The complaint alleging lack of care for former client, violation of personal rights and uncleaned kitchen 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 allegations could not have happened and/or are without a reasonable basis.

Former client was admitted in January 2025 and retained private caregivers for about one month. He was prescribed Lorazepam for anxiety and had a urinary foley catheter. Client began receiving hospice care in February, and passed away in March 2025. Based on review of records and interviews with staff and witnesses, there is no evidence that staff sedated client, left him in soiled diapers, handled client roughly or yelled at him.
LPA observed that kitchen is neat and clean. Information about the poor cleanliness of kitchen was not obtained.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2