435202753-4-1-2025-26-AS-KHOS-DFHS9S-20250407134114

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202753
Report Date: 04/01/2025
Date Signed: 04/01/2025 10:38:54 AM

Unsubstantiated

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
12/23/2024 and conducted by Evaluator Marcela Yanez

COMPLAINT CONTROL NUMBER: 26-AS-20241223170818

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:	04/01/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Fonokalafi Jano, Lead Staff		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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Facility staff is violating personal rights by not allowing visitors inside facility
Facility staff is not administering medication to residents according to physician orders.
Facility staff is not addressing resident significant weight loss
Residents do not have access to telephone in the facility

INVESTIGATION FINDINGS:

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On 04/01/2025 at 9:45 AM Licensing Program Analyst (LPA) Marcela Yanez subsequent conducted an unannounced complaint investigation visit to deliver findings on the above allegations. LPA met with Lead Staff Fonokalafi Jano and stated the purpose of the visit.

On 12/23/2024 the Department received a complaint with allegations that the facility is not addressing significant weight loss of the resident, the staff is not allowing visitors inside the facility, the staff is not administering medication according to doctor’s order, and the residents not having access to the telephone.

During the course of investigation, LPA interviewed 3 staff (S1-S3). LPAs obtained records for 3 Residents (R1-R3) which consisted of Physicians Report, Medication Administration Record, facility menu, and residents weight log.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20241223170818

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: 04/01/2025

NARRATIVE

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LPA interviewed ADM to address the allegation of significant weight of weight loss of resident. ADM stated that the residents weight fluctuates, and it is documented on the weight record log and any significant weight loss is immediately reported to their Physician. ADM stated that some residents have dietary restrictions that are documented in the residents file in the Physicians Report. LPAs reviewed monthly weight log of residents and there was no significant weight loss.

LPAs interviewed Staff S1-S2 both stated visitors are allowed in the facility and can visit in the front room where there is a loveseat or the common area or patio in backyard and in the resident’s bedrooms. S1 and S2 stated that during the pandemic Covid-19 the facility had restrictions before entering the facility such as Covid-19 rapid tests and body temperature check. During LPAs visit LPAs observed a resident’s visitors in resident bedrooms.

During visit LPA observed three phone receivers accessible to residents in care located in the kitchen common area and the front office/sitting area. ADM stated the facility is equipped with audio enhancing devices for the residents who are hearing impaired. ADM showed LPAs the device.

During investigation LPA reviewed centrally stored medication record and reviewed medication with staff and based on record review the medication count was accurate and medication was administered as prescribed by physicians.

Based on observations, interviews and document review the above allegations are UNSUBSTANTIATED.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

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

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025

LIC9099 (FAS) - (06/04)

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