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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202753
Report Date: 01/30/2025
Date Signed: 01/30/2025 12:16:46 PM

Document Has Been Signed on 01/30/2025 12:16 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:
01/30/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Administrator, Dieu-Qui H NguyenTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on the deficiencies cited on 12/30/2024. LPA Rai met with Administrator, Dieu-Qui H Nguyen and stated the purpose of today's visit.

During visit, LPA observed 3 staff and 5 residents at the facility. 2 Out of the 3 staff were associated to the facility and obtained a Criminal Record Clearance. Staff (S2) is working at the facility as a caregiver, providing care and supervision and does not have a Criminal Record Clearance and associated to the facility.

During visit, LPA observed S2 assisting R1 with walking from R1's bedroom to the living room. S2 stated he/she provides care and supervision to the residents in care. LPA Rai observed S2's medication bottles with medications in staff room.

During visit, LPA Rai did observe S3's staff file to be complete and present in the facility for LPA Rai to review.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809-D. A civil penalty is being assessed for the amount of $500 for S2 working in the facility for more than 5 days without receiving criminal record exemption transfer approval. The civil penalty will be for $500 ($100 per day x 5 days = $500). See LIC421BG.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. LPA Rai provided Letter of Deficiency Citations Cleared.
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: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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 01/30/2025 12:16 PM - It Cannot Be Edited


Created By: Simranjit Rai On 01/30/2025 at 10:34 AM
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: 01/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department...
This requirement is not met as evidenced by:
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Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure to obtain a Criminal Background Clearance for S2 prior to working in the facility by POC due date. Licensee/Administrator agreed and understood.
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Based on record review and interview, the Licensee did not ensure S2 obtained a Criminal Background Clearance prior to working at a licensed facility which poses/posed an immediate 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: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
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