Community Care Licensing

Document Has Been Signed on 01/23/2024 10:17 AM - It Cannot Be Edited

FACILITY NAME:	HERITAGE ROYALE		FACILITY NUMBER:	415600858
ADMINISTRATOR:	DELA CRUZ, ANICIA		FACILITY TYPE:	740
ADDRESS:	2 HENRY PLACE		TELEPHONE:	(650) 697-8930
CITY:	MILLBRAE	STATE: CA	ZIP CODE:	94030
CAPACITY: 6		CENSUS: 5	DATE:	01/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Anna Villanueva and Katie Eiseman		TIME COMPLETED:	08:00 PM

SUPERVISORS NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024

Link to Parent Document Below:

FACILITY NAME: HERITAGE ROYALE	FACILITY NUMBER: 415600858
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as Ajax cleanser and Drano are stored in unlocked and accessible under sink cabinet in common bathroom near rooms #1 and #2, which posed an immediate health, safety or personal rights risk to persons in care. Licensee failed to ensure that cleaning products are stored where inaccessible to clients.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	Ajax and Drano were removed from client bathroom in LPA's presence. Deficiency corrected and cleared.

Type A

Section Cited

CCR

87355(e)(3)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above, as 2 out of 6 staff do not have criminal record clearance associated to this facility, which poses an immediate health, safety or personal rights risk to persons in care. Staff #1 and #3 do not have criminal record clearance associated to this facility.
	POC Due Date: 01/22/2024
	Plan of Correction
1 2 3 4	Requests to transfer criminal record clearances for staff #1 and #3 to be sent to CCLD BY DUE DATE

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024

Link to Parent Document Below:

FACILITY NAME: HERITAGE ROYALE	FACILITY NUMBER: 415600858
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

Type B

Section Cited

CCR

87307(d)(6)

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as square 4-legged table is placed in front of exit door in room #3, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	Table was relocated away from exit door in LPA's presence. Deficiency corrected and cleared.

Type B

Section Cited

CCR

87412(a)(11)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of staff records, the licensee did not comply with the section cited above in 3 out of 6 staff, which poses a potential health, safety or personal rights risk to persons in care. Health Screenings and/or TB test results are missing for staff #1, #2, #5.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Health screenings and /or TB test results for S1, S2, S5 to be submitted to CCLD BY DUE DATE

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024

Link to Parent Document Below:

FACILITY NAME: HERITAGE ROYALE	FACILITY NUMBER: 415600858
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

Type B

Section Cited

CCR

87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above, as 4 out of 6 staff do not have current first aid training, which poses a potential health, safety or personal rights risk to persons in care. Staff #2, #3, #4, #5 do not have current first-aid training.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Proof of current first aid training for S2, S3, S4, S5 to be sent to CCLD BY DUE DATE

Type B

Section Cited

HSC

1569.626(a)(1)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of staff training records, the licensee did not comply with the section cited above, as there is no evidence that staff have received required dementia training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Proof of required dementia training for all staff will be submitted to CCLD BY DUE DATE.

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024

Link to Parent Document Below:

FACILITY NAME: HERITAGE ROYALE	FACILITY NUMBER: 415600858
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

Type B

Section Cited

HSC

1569.69(a)(2)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of staff training records, the licensee did not comply with the section cited above, as Staff who handle medications do not have required medications training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Proof of required medications training for staff who handle medications will be submitted to CCLD BY DUE DATE

Type B

Section Cited

CCR

87465(h)(5)

(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. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as clients' medications are prepoured 3 days in advance, as small plastic cups containing pills are observed for 3 days. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	This practice must CEASE IMMEDIATELY, and proof/certification of correction to be submitted to CCLD BY DUE DATE

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024

Link to Parent Document Below:

FACILITY NAME: HERITAGE ROYALE	FACILITY NUMBER: 415600858
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and confirmation of staff, the licensee did not comply with the section cited above, as there is no record of disaster drills. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Disaster drills will be scheduled and conducted quarterly. Proof/plan of correction to be submitted to CCLD BY DUE DATE.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024