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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202753
Report Date: 12/30/2024
Date Signed: 12/30/2024 05:38:04 PM

Document Has Been Signed on 12/30/2024 05:38 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HEATHERFIELD INNFACILITY NUMBER:
435202753
ADMINISTRATOR/
DIRECTOR:		NGUYEN, DIEU-QUI HFACILITY TYPE:
740
ADDRESS:1021 HEATHERFIELD LANETELEPHONE:
(408) 621-9887
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 9CENSUS: 5DATE:
12/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Administrator, Dieu-Qui H NguyenTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez conducted an unannounced visit to conduct an investigation visit for a complaint received on 12/23/2024. During the complaint investigation, a case management was conducted due to deficiencies observed during the investigation process. LPAs met with Administrator Dieu-Qui H Nguyen.

During today's visit, LPAs observed 2 staff at the facility and providing care and supervision to the residents in care. S1 was preparing snacks for the residents and S2 was providing incontinence care to residents. LPAs reviewed LIS 536 Facility Personnel Report Summary for the facility dated 12/30/2024. Administrator stated both staff had Criminal Record Clearance and provided the names of the 2 staff. LPAs were able to verify S1's name on the LIS 536 but the name S2 provided was not on the LIC 536. Administrator provided a different name for S2 than S2 stated to LPAs. Administrator stated S2 has obtained a Criminal Record Clearance.

LPAs requested staff file for S2. Administrator was not able to provide a complete staff file for S2 which would include S2's letter of Criminal Record Clearance. The only document from S2's staff file Administrator was able to provide for LPAs to review was the training completed for 2024. Administrator stated S2's file is maintained out of the facility in a separate location. Administrator did not maintain S2's staff file at the facility and was not available for licensing agency to review.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809-D. This report was reviewed with Administrator Dieu-Qui H Nguyen and a copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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 12/30/2024 05:38 PM - It Cannot Be Edited


Created By: Simranjit Rai On 12/30/2024 at 04:02 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HEATHERFIELD INN
FACILITY NUMBER: 435202753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2025
Section Cited
CCR
87412(g)

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87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
This requirement is not met as evidenced by:
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Administrator stated to submit a written plan of action understanding regulation and will ensure staff files are maintained at the facility and be available to the licensing agency for review by POC due date. Administrator agreed and understood.
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Based on record review and interview, Licensee did not maintain staff file for S2 at the facility and was not available to the licensing agency for review which poses/posed a potential health, safety or personal rights risk to persons 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:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
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