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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601197
Report Date: 02/27/2026
Date Signed: 02/27/2026 07:06:29 PM

Document Has Been Signed on 02/27/2026 07:06 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:UNIFIED HEARTS HOME CAREFACILITY NUMBER:
415601197
ADMINISTRATOR/
DIRECTOR:		CHEN, LINAFACILITY TYPE:
740
ADDRESS:630 VANESSA DRTELEPHONE:
(415) 215-6807
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 6CENSUS: 6DATE:
02/27/2026
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:John Skaggs, Jim MedranoTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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LPA Jeung toured facility and grounds of this two level facility. There are 6 bedrooms--each of which exits to exterior, 2 bedrooms have full private bathrooms and one has a private half bathroom--two common full bathrooms, a great room which includes dining area, and kitchen. On the upper level, there is a large staff bedroom with two bunk beds, large office space, and full bathroom; this level is not used by residents. Emergency signal system by Smart Caregiver Corp. is installed and consists of pendant alarms for each bedroom that transmit an audible alert--that also identifies the room of origin--to central unit in the kitchen. and two pagers Carbon monoxide detectors are present and operable. Clothes washer and dryer are located in the 2-car garage. Property is level, mostly paved, and fenced.
Medications are stored in locked kitchen cabinet and toxins are stored in garage. It is recommended that a storage cabinet be installed in garage to secure chemicals. Hot water temperature is tested at 113 degrees in common bathroom. Food preparation and service items are present, as well as non-perishable fruits, vegetables and protein. Supplies of bed and bath linens and hygiene products are observed. First aid kit is complete. Staff and client files are reviewed, including Centrally Stored Medications Records.
Lina Chen holds a valid RCFE administrator certificate (x 1/27), as does assistant administrator John Skaggs (x 5/27).

Proof of current liability insurance is requested to be sent to CCLD within SEVEN days.

Deficiencies of the California Code of Regulations, Title 22 are cited on following pages. See also Technical Advisory Notes--5 pages.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2026
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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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)
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Document Has Been Signed on 02/27/2026 07:06 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/27/2026 at 05:57 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: UNIFIED HEARTS HOME CARE
FACILITY NUMBER: 415601197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/27/2026
Section Cited
CCR
87355(c)

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CRIMINAL RECORD CLEARANCE TRANSFER
A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another...by providing ...documents to the Department. This requirement is not met, as criminal record clearance for staff #2 is not yet associated to this facility.
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Criminal record clearance for staff #2 was associated to this facility in LPA's presence.
Deficiency corrected and cleared.
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Licensee failed to ensure that all staff with client contact maintain criminal record clearance and association to facility, which poses an immediate health or safety risk to clients in care. Staff #2 started working 2/8/26.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/27/2026 07:06 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/27/2026 at 06:06 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: UNIFIED HEARTS HOME CARE
FACILITY NUMBER: 415601197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2026
Section Cited
CCR
87307(a)

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PERSONAL ACCOMMODATIONS/SVCS
Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others... This requirement is not met, as sofa in living room
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Staff shall cease sleeping in living room. Proof/plan of correction to be sent to CCLD BY DUE DATE, describing how this deficiency has been corrected.
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is used by staff for sleeping at night. Licensee failed to ensure that common areas are reserved for common use, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
03/06/2026
Section Cited
CCR87465(h)(6)

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INCIDENTAL MEDICAL CARE
A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and
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Rx and OTC medications for clients #1 and #2 are recorded on Centrally Stored Medications Records in LPA's presence.
Plan of correction to address this deficiency shall be sent to CCLD BY DUE DATE
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instructions. This requirement is not met, as 6 Rx & OTC meds for client #2 are not recorded on Centrally Stored Medications REcords, and OTC Robitussin for client #1 is not logged. Licensee failed to ensure that there is a written record of all centrally stored client medications, which poses a potential risk.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/27/2026 07:06 PM - It Cannot Be Edited


Created By: Audrey Jeung On 02/27/2026 at 06:23 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: UNIFIED HEARTS HOME CARE
FACILITY NUMBER: 415601197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2026
Section Cited
HSC
1569.626

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HEALTH AND SAFETY CODE
All RCFEs shall meet the following training requirements.... for all direct care staff: 12 hours of dementia care training, 6 of which shall be completed before a staff member begins working independently with residents...remaining 6 hours of which shall
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New staff shall receive required 12 hours of dementia training and proof of correction to be sent to CCLD BY DUE DATE
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 be completed within the first 4 weeks of employment. This requirement is not met, as staff #4 has been employed for over 4 weeks, and only received 5 hours of dementia training. Licensee failed to ensure that new staff received required dementia training, posing a potential risk to clients.
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Type B
03/06/2026
Section Cited
CCR87411(c)(1)

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PERSONNEL REQUIREMENTS GENERAL
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 staff #1 and #4 do not have proof of current first aid training, which poses a potential
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Proof of current first aid training for staff #1 and #4 will be sent to CCLD BY DUE DATE
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health, safety, or personal rights risk to clients 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2026


LIC809 (FAS) - (06/04)
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