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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601085
Report Date: 06/14/2024
Date Signed: 06/14/2024 07:12:03 PM

Document Has Been Signed on 06/14/2024 07:12 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:HEARTS AT MILLWOOD ASSISTED LIVINGFACILITY NUMBER:
415601085
ADMINISTRATOR/
DIRECTOR:		ERMITANO, ELI HARTFACILITY TYPE:
740
ADDRESS:416 MILLWOOD DRTELEPHONE:
(650) 777-8166
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 5DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Imelda Mendoza & Carol CorpuzTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
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LPA Audrey Jeung toured facility and grounds. This one level facility consists of 6 private client rooms--4 of which have private half or full bathrooms--2 staff rooms, bath/shower room, living/dining area, kitchen, and attached garage. Three residents currently receive hospice services. There is a detached storage shed in backyard. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. There is no signal system in place, as facility employs awake overnight staff. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete.

A staff room above 1-car garage has 3 beds and rear room on left side has a bunk bed and half bathroom. The backyard is fenced and accessible by 5 bedrooms with exit doors.
Medications are stored in locked hall closet. Chemicals and cleaners are stored in garage and locked detached storage shed.
An updated Disaster and Mass Casualty Plan is posted, and copy is given to LPA. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed.
Eli Ermitano is a certified RCFE administrator (x10/24) that oversees facility operations.
Client and staff records are reviewed.

The following information is requested to be submitted to CCL by 6/28/24:

Current proof of liability insurance for $1 million per incident and $3 million in annual aggregate.

Deficiencies of the California Code of REgulations, Title 22 are cited on a following page. See also Technical Advisory Notes--3 pages.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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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Document Has Been Signed on 06/14/2024 07:12 PM - It Cannot Be Edited


Created By: Audrey Jeung On 06/14/2024 at 06:25 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: HEARTS AT MILLWOOD ASSISTED LIVING
FACILITY NUMBER: 415601085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, as 2 residents use half bed rails, but there are no MD orders maintained. This poses a potential health, safety or personal rights risk to persons in care.
Clients #4 and #5 are not on hospice and have half bed rails on their beds. There are no MD orders maintained.
POC Due Date: 06/28/2024
Plan of Correction
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MD orders for half bed rails for clients #4 and #5 will be sent to CCLD BY DUE DATE.
Type B
Section Cited
HSC
1569.69
Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above, as 2 staff have not received annual 8 hours of medication training, which poses a potential health, safety or personal rights risk to persons in care.
Caregivers #1 and #2 received medication training over 12 months ago. They pass medications to residents.
POC Due Date: 06/28/2024
Plan of Correction
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Proof of required 8 hours of continuing medications training for staff #1 and #2 and all other continuing staff will be sent to CCLD BY DUE DATE
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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
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