435202753-8-11-2020-26-AS-YNGG-BSE276-20200811170812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202753
Report Date: 08/06/2020
Date Signed: 08/11/2020 05:08:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	HEATHERFIELD INN		FACILITY NUMBER:	435202753
ADMINISTRATOR:	NGUYEN, DIEU-QUI H		FACILITY TYPE:	740
ADDRESS:	1021 HEATHERFIELD LANE		TELEPHONE:	(408) 621-9887
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95132
CAPACITY:	9	CENSUS: 5	DATE:	08/06/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Dieu-Qui Nguyen		TIME COMPLETED:	04:22 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced tele-pre-licensing inspection. Due to current COVID-19 situation, LPA met with the Prospective Administrator (PA) Dieu-Qui Nguyen virtually via FaceTime. Fire clearance granted this facility a capacity of total 9 residents; 2 bedridden residents and 7 non-ambulatory residents. There were 5 rooms for residents in the facility. At 11:17 AM, LPA toured the facility virtually with PA. LPA observed there were posters at the entrance reminding everyone to wash hands and use safety precaution due to COVID-19. There was a screening station to measure temperature of any people coming from outside. There were complaint poster, ombudsman poster, resident's right to counsel posters, etc. near the entrance. The facility was well lit. LPA observed windows screen and the facility were in good repair. LPA observed residents were practicing social distancing doing various activities, at least 6-feet apart from each other. LPA toured all residents' rooms. All rooms were equipped with furniture, beds, and functioning lights. All restrooms also had functioning lights, and grab bars. All rest rooms were equipped with grab bars and nonskid mats. The hot water temperature in room 1 and common restroom were measured to be 116 and 115 degrees F respectively. LPA randomly sampled the carbon monoxide and smoke detectors to be in working condition. 2 fire extinguishers were last serviced on 7/10/2020. The medication cabinets were locked and inaccessible by residents. LPA did not observe any toxic substances or sharp objects accessible to residents. LPA observed there were at least 2 days of perishable and 7 days of nonperishable of food in the refrigerators and the storage areas. Page 1 of 2

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2020

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HEATHERFIELD INN	FACILITY NUMBER: 435202753
	VISIT DATE: 08/06/2020

NARRATIVE

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There were no obstructions in the passageways throughout the facility. Alarm at the door going to the outside of the facility was observed to be functioning. There was no open body of water in the garden. There was also no obstruction at the emergency exit

At 2:30 PM, LPA sampled and audited the residents and staff records. All residents' files contained signed copies of their admission agreement and current copies of physician's reports, and appraisals/needs and services plans. All staff records had current training, first-aid certificates, criminal background clearance from Community Care Licensing and were associated to this facility.

Pre-Licensing Inspection Tool was completed and LPA gave an COMP III orientation to PA.

No issues noted during the pre-licensing inspection. The physical plant is approved pending the completion of Centralized Application Bureau (CAB) review of the facility application.

This report was emailed to PA for signature and reference.

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SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2