<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600693
Report Date: 12/17/2025
Date Signed: 12/17/2025 01:47:06 PM

Document Has Been Signed on 12/17/2025 01:47 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:AM RESIDENTIAL CARE HOMEFACILITY NUMBER:
415600693
ADMINISTRATOR/
DIRECTOR:		EISEMAN, KATIEFACILITY TYPE:
740
ADDRESS:1000 BALBOA AVENUETELEPHONE:
(650) 348-8212
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 6DATE:
12/17/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Katie EisemanTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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 December 17, 2025, Licensing Program Analyst (LPA) Murial Han conducted a case management visit to follow-up on the pre-licensing inspection findings that were observed for Heritage Manor. LPA met with administrator, Katie Eiseman explained the purpose of today's visit.

During the pre-licensing inspection, LPA observed sharps were not locked and accessible to residents in care.

During medication review, LPA observed some of resident #1 (R1), resident #3 (R3), and resident #6 (R6)'s medications did not have a written order from the physician.

During the medication review, LPA also observed resident #2 (R2), resident #4 (R4), resident #5 (R5), and R6's medications were removed from its original contains and pre- poured into a weekly medication organizer. According to Staff #1 (S1), the medications were prepared for a later shift.

LPA requested for a copy of the current medication list/prescription for R1, R3 and R6 to be submitted by 12/18/2025.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the administrator.

A copy of this report and the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
Document Has Been Signed on 12/17/2025 01:47 PM - It Cannot Be Edited


Created By: Murial Han On 12/17/2025 at 12:53 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: AM RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2025
Section Cited
CCR
87309(a)

1
2
3
4
5
6
7
(a) Except as specified in subsection..the licensee shall ensure that..sharp objects,other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
1
2
3
4
5
6
7
The administrator has relocated all the sharps to a more secured/locked storage area. The administrator will re-train staff.
8
9
10
11
12
13
14
This requirement is not met as evidence by based on observation, and interview, LPA observed sharps were unlocked and accessible to residents in care which poses an immediately health and safety risks to residents in care.
8
9
10
11
12
13
14
The administrator will provide a copy of the plan of correction to CCL by 12/18/2025 to ensure compliance and the plan shall indicate the date that the re-training of staff will be completed.
Type A
12/18/2025
Section Cited
CCR87465(e)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Caree)For every prescription and nonprescription PRN medication..there shall be a signed, dated written order from a physician,..
1
2
3
4
5
6
7
The administrator will work with the responsible parties to ensure compliance. The administrator will provide a plan of correction that includes the action taken to resolve the deficiency, and the plan of
8
9
10
11
12
13
14
This requirement is not met as evidenced by based on observation, record review and interviews, LPA observed some of R1, R3, and R6 medications did not have a written physician order which poses an immediately health and safety risk to residents in care.
8
9
10
11
12
13
14
correction to ensure staff is re-trained. The administrator will provide a copy of the plan of correction to CCL by 12/18/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/17/2025 01:47 PM - It Cannot Be Edited


Created By: Murial Han On 12/17/2025 at 01:09 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: AM RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2025
Section Cited
CCR
87465(h)(5)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container...
1
2
3
4
5
6
7
The administrator will provide a plan of correction to ensure compliance and the plan shall indicate how is the facility going to prevent this from happening again and it shall include
8
9
10
11
12
13
14
This requirement is not met based on observation, and interview, LPA observed R2, R4, R5, and R6's medications were transferred to a weekly medication organizer for a later shift which poses an immediate health and safety risks to residents in care.
8
9
10
11
12
13
14
staff re-training. The administrator will provide a copy of the plan to CCL by 12/18/25.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4