435202753-1-11-2024-26-AS-KHOS-D4CTG8-20240415144242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202753
Report Date: 01/11/2024
Date Signed: 01/11/2024 05:02:34 PM

Substantiated

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
10/11/2021 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20211011110448

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:	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Administrator Dieu-qui H Nguyen		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility screen door is broken

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Dieu-qui H Nguyen

On October 11, 2021, the Department received a complaint alleging facility screen door is broken.

On October 19, 2021, LPA Anna Bui conducted an unannounced 10-day complaint investigation visit. LPA toured the facility and observed a tear along the vertical side of the lower portion of the screen door, in bedroom #4. LPA took photographs of the screen door.

LPA Bui interviewed staff S1. S1 stated the screen door in Room #4 was broken for about a week.

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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-20211011110448

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: 01/11/2024

NARRATIVE

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On January 11, 2024, LPA observed resident bedroom #4 with a damaged facility screen door. ADM confirmed that resident bedroom #4 has a damaged screen door.

The Department has investigated the above allegation. Based on observation, resident bedroom #4’s sliding screen door had a tear and was broken. The preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. Exit interview was conducted with Administrator Dieu-qui H Nguyen and a copy of the signed report & appeal rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20211011110448

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/18/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include ... for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by;	1 2 3 4 5 6 7	ADM stated she will send plan of action on how the facility will ensure facility screens shall be in good repair. ADM stated she will send POC to LPA by 11/18/2024.
	8 9 10 11 12 13 14	Based on LPA's observation, bedroom #4's screen door has holes and is not in good repair. ADM confirmed that the screen door is damaged as well. This poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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