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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600858
Report Date: 08/21/2024
Date Signed: 08/21/2024 03:19:09 PM

Document Has Been Signed on 08/21/2024 03:19 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 ROYALEFACILITY NUMBER:
415600858
ADMINISTRATOR/
DIRECTOR:		EISEMAN, KATIEFACILITY TYPE:
740
ADDRESS:2 HENRY PLACETELEPHONE:
(650) 697-8930
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 4DATE:
08/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator - Katie EisemanTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 07/18/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with caregiver Lojie Fernando upon arrival and explained the purpose of today's visit. Around 2pm the administrator Katie Eiseman arrived and met with LPA.

LPA was allowed entry into the facility. This is a single level facility approved all residents to be non-amblatory and three hospice residents. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer between the stove and refrigerator. Medications are observed to be locked in a lockable storage area in the office of the facility. Perishable and non-perishable food items are observed as in place. There are additional refrigerators and freezers in the garage area which also carry additional food supplies. First aid kit is observed as complete with required items located in the office area of the facility. LPA observed that there are multiple fire extinguishers in place inspected 08/15/2024, smoke detectors, carbon monoxide detectors are observed in place through out the facility, and central heating system. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 06/24/2025. Water temperature was measured at 110F in two common resident bathrooms and a private bathroom in a vacant resident room.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HERITAGE ROYALE
FACILITY NUMBER: 415600858
VISIT DATE: 08/21/2024
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LPA observed rooms numerous resident rooms and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Three resident bedrooms contain a full bathroom. Resident linen supplies are observed as in place. Cleaning supplies are also observed as locked inaccessible to residents in care. There is a live in staff area for sleeping also located in the office. Facility does not handle resident monies. Four of four resident files are reviewed as current. Medications are inspected and observed to be current and in order.

The following updated forms are requested to be submitted to CCLD by 08/28/2024:

• Copy of updated Administrator Certificates
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property

No citations issued during today's visit. Report is reviewed with Katie and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC809 (FAS) - (06/04)
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