435202753-11-15-2024-26-AS-KHOS-DBCQXH-20241125113333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202753
Report Date: 11/15/2024
Date Signed: 11/15/2024 04:52:19 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2024 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20240305131931

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:	11/15/2024
		UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	Fonokalafi Jano		TIME COMPLETED:	04:39 PM

ALLEGATION(S):

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Staff do not keep the facility free from pests.
Staff do not properly maintain the facility grounds.
Staff are not providing adequate laundry service.
Staff residing in the facility do not have a Criminal Record Clearance.
Staff providing care and supervision have not completed required training.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Staff Head Fonokalafi Jano (SH)

On 3/5/2024, the Department received a complaint with the above allegations.

On 3/12/2024, the Department conducted an initial investigation visit.

LPA toured the facility inside and out. LPA interviewed 2 staff and 2 residents.

LPA requested staff training documents.

Continue on LIC9099-C. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20240305131931

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 INN	FACILITY NUMBER: 435202753
	VISIT DATE: 11/15/2024

NARRATIVE

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Staff do not keep the facility free from pests:
Staff do not properly maintain the facility grounds:

On 3/12/2024, LPA interviewed staff S1. S1 stated the facility staff are required to sweep the floor three times a day. S1 stated resident R1's dog cannot be in the dining room when the residents are eating their food in the dining room. S1 stated the staff sweep the floor before the residents eat for breakfast, lunch and dinner. S1 stated there is maintenance services for the front yard and backyard.

During the visit, LPA observed the front area clean and had no obstruction which poses a health or safety hazard. LPA did not observe items that poses health or safety concern. LPA observed the kitchen, dining room area, and sitting area were kept clean and free of litter, rodents, vermin and insects. LPA observed the 4 resident rooms, 2 resident bathrooms, laundry room, outside and staff room were clean and free of litter, rodents, vermin and insects.

LPA observed two staff cleaning bathrooms and resident bedrooms during LPA's visit.

Staff are not providing adequate laundry service:

On 3/12/2024, LPA interviewed staff S2. S2 stated residents have shower every other day, and there is a schedule for resident showers. S2 stated facility staff strip residents' bed and change the linens on the day that residents have showers. S2 stated residents have schedule for showers posted on the whiteboard. LPA observed the resident's shower schedule on the whiteboard. LPA observed a note from ADM which stated "All bedding will be changed and laundered on shower days" and "All client laundry will be washed on Thursdays".

LPA observed the 4 resident rooms, 2 resident bathrooms clean and free of litter. LPA observed the laundry machines not broken. LPA observed resident rooms and laundry hampers were not overflowing.

There is no evidence to indicate staff are not providing adequate laundry service.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20240305131931

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 INN	FACILITY NUMBER: 435202753
	VISIT DATE: 11/15/2024

NARRATIVE

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Staff residing in the facility do not have a Criminal Record Clearance:

On 3/12/2024, LPA interviewed staff S1 and checked S1 with the facility personnel report summary. S1 is Criminal Record Clearance and is associated to the facility.

LPA interviewed staff S2 and checked S2 with the facility personnel report summary, S2 is Criminal Record Clearance and is associated to the facility.

S2 stated there are staff members that come earlier than their shift and sleep at the facility. S2 provided the names of staff S3, S4 and S5. LPA checked S3, S4 and S5 with the facility personnel report summary, and they are Criminal Background Clearance and are associated to the facility.

LPA observed 3 staff (S4, S6, S7) in the facility and checked staff S6, S7 with the facility personnel report summary. Both staff are Criminal Background Clearance and are associated to the facility.

Staff providing care and supervision have not completed required training:

On 3/12/2024, staff S1 showed LPA the staff training documents on the cell phone.

LPA obtained a copy of 4 caregivers training documents. Based on the review of the training log, 4 Out of 4 caregivers completed the required training.

No evidence to indicate staff have not completed required training.

The Department has investigated the above allegations. Based on the investigation, records reviewed, observation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. This report was provided to review and for signature. A copy of this report was provided to ADM.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC9099 (FAS) - (06/04)

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