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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600858
Report Date: 01/19/2024
Date Signed: 01/19/2024 06:32:43 PM


Document Has Been Signed on 01/19/2024 06:32 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HERITAGE ROYALEFACILITY NUMBER:
415600858
ADMINISTRATOR:DELA CRUZ, ANICIAFACILITY TYPE:
740
ADDRESS:2 HENRY PLACETELEPHONE:
(650) 697-8930
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:6CENSUS: 5DATE:
01/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Anna Villanueva and Katie EisemanTIME COMPLETED:
05:00 PM
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In response to Death Report submitted to CCLD on 1/3/24 of client's death on 12/26/23, LPA Jeung requested to review MD report and appraisal, which were previously requested but not received. Client experienced a medical emergency, and staff contacted client's responsible party, who directed staff NOT to call 9-1-1. Client had a Physician's Orders for Life-Sustaining Treatment (POLST) on file, which stated that comfort measures only should be provided.

MD report is not available for LPA to review, so cause of death is unknown.

Deficiency of the California Code of Regulations, Title 22, is cited on a following page.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
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
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 2


Document Has Been Signed on 01/19/2024 06:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: HERITAGE ROYALE
FACILITY NUMBER: 415600858

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2024
Section Cited
CCR
87465(g)

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INCIDENTAL MEDICAL CARE
The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections
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Plan of correction to be submitted to CCLD BY DUE DATE
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87469(c)(2), (c)(3), or (c)(4).
This requirement was not met, as staff failed to call 9-1-1 on 12/26/23 when client #1 experienced a medical emergency. Licensee failed to ensure that 9-1-1 was called to determine what, if any measures should be taken. This posed a potential health, safety or personal rights risk to client in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
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
LIC809 (FAS) - (06/04)
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