435202753-4-11-2024-26-AS-KHOS-D4CTG7-20240415144241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202753
Report Date: 04/11/2024
Date Signed: 04/11/2024 03:47:05 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
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: 5	DATE:	04/11/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator Dieu-qui H Nguyen		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident had to wait a few hours for incontinence care
Facility TV is not functional
Food at facility does not meet the recommended dietary food allowance

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 Administrator (ADM) Dieu-qui H Nguyen.

Facility TV is not functional

On October 11, 2021, the Department received a complaint alleging Facility TV is not functional.

On October 19, 2021, LPA Bui conducted an unannounced 10-day complaint investigation visit. LPA toured the facility and observed 3 Out of 3 resident televisions turned on. LPA observed the living room television was also functional.

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Unfounded

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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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 9

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: 04/11/2024

NARRATIVE

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On January 11, 2024, LPA Manuel Monter toured the facility and resident bedrooms. LPA observed all resident’s 4 Out of 4 televisions as functional. LPA observed the television in the facility living room as functional.

LPA Monter interviewed the ADM and four staff members, S1-S4. ADM the televisions in the facility work. 4 Out of 4 staff interviewed stated the televisions at the facility work. S1 stated if a television doesn’t work, they can just swap that television with another one from the bedrooms that are not occupied.

On January 11 & 13, 2024 & October 14, 2021, the Department interviewed residents, R1-R5. 1 Out of 5 residents stated their television in their bedroom did not work. 2 Out of 5 residents stated the televisions in the facility work. The remaining 2 Out of 5 residents interviewed stated they did not want to be interviewed.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

Resident had to wait a few hours for incontinence care

On October 11, 2021, the Department received a complaint alleging a resident had to wait a few hours for incontinence care.

On October 19, 2021, LPA Bui interviewed 2 staff (S1 & S2). S1 stated staff do night rounds every 2 hours at night and that's when they check if a resident needs their diaper changed. S1 and S2 stated R1 had a bell she could ring if she needed assistance at night. S1 and S2 stated residents did not have to wait a few hours to get their diaper changed.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 9

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: 04/11/2024

NARRATIVE

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On October 12, 14 and 19, 2021, the Department interviewed residents R1-R3. R1 stated staff did not respond to his/her request for assistance with incontinence needs and he/she had to lay wet for 2-3 hours. R1 stated he/she was given a bell to ring if he/she needed help. R1 stated the facility was aware he/she needed assistance changing his/her undergarments, and staff helped him/her about 3 times per night. R1 stated the night staff realized he/she needed his/her undergarments changed more at night, like up to 4 times at night. R1 stated someone always responded, but it took them a long time to get there. R2 was unable to answer LPA’s questions due to neurocognitive disorder. R3 stated he/she did not have to wait a long time for assistance with the bathroom.

On January 11 & 13, 2024, LPA Manuel Monter interviewed residents, R2-R5. 2 Out of 4 residents stated the facility does assist them with toiletry needs in a timely manner. The remaining 2 Out of 4 residents interviewed stated they did not want to be interviewed.

On January 11, 2024, LPA Manuel Monter interviewed staff S1-S4 and ADM. 4 Out of 4 staff members stated, the facility changes residents every two hours. 2 Out of 4 staff members stated, the residents have call bells to ring if they need assistance. S4 stated he/she the residents are checked every 2 hours and to re-position them as well. ADM stated the facility has a rotation of staff checking the residents throughout the night. ADM stated the residents ring for help, the staff will respond. ADM stated if a resident needs to be changed, then the facility staff will help that resident and they will be changed. The staff respond very quickly if a resident calls for help.

On January 11 & 13, 2024 and February 27, 2024 LPA Manuel Monter toured the facility. LPA did not observe or smell any residents who were left soiled during LPA’s visit.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 9

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: 04/11/2024

NARRATIVE

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Food at facility does not meet the recommended dietary food allowance

On October 11, 2021, the Department received a complaint alleging food at facility does not meet the recommended dietary food allowance.

On October 12, 14 & 19, 2021, The Department interviewed residents, R1-R3. R1 stated the food service is inadequate. R1 stated residents are given 1 or 2 pieces of triangle toast with a muffin, sandwiches for lunch. R1 stated residents are also given half a slice of toast with 1 or two strawberries cut into small pieces. Residents R2 and R3 stated the food is fine.

LPA Bui interviewed staff S1 and S2. S1 stated she cooks for the residents and the menu is posted on the board. S1 stated no residents have complained about the food. S2 stated the residents gets food like oatmeal and bananas for breakfast, sandwiches for lunch, chicken or beef and vegetables for dinner. S2 stated residents have not complained about the food.

On January 11 & 13, 2024, LPA Manuel Monter interviewed residents, R2-R5. 2 Out of 4 residents stated the home makes a variety of food that they like and makes food that meets their needs. The remaining 2 Out of 4 residents interviewed stated they did not want to be interviewed.

On January 11, 2024, LPA Manuel Monter interviewed staff S1-S4 and ADM. 4 Out of 4 staff stated the home makes healthy food for the elderly residents. S1 stated the facility will also make the foods that the residents request. S1 stated the home makes food to meet the residents needs as they high cholesterol and we need to be careful what we serve them. ADM stated the types of food the home makes is based on the dietary needs the elderly have. ADM stated the facility also use spices to avoid using salt. ADM stated the facility also provide vegetables; kale, tomatoes, butternut squash, lettuce. Fruits, bananas, prune bread.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 9

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: 04/11/2024

NARRATIVE

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On January 11 & 13, 2024 and February 27, 2024 LPA Manuel Monter conducted an unannounced complaint investigation. LPA toured the home and observed the facility’s food supply. LPA observed sufficient 2-day perishable and 7 day non perishable food supply. LPA observed a variety of vegetables and fruit. LPA also observed staff asking residents what they would like to eat the following day. On January 11, 2024, LPA observed residents eating lunch, which included a vegetable soup, a sandwich with a fruit salad. On January 13, 2024, LPA observed residents eating breakfast which included a veggie omelet, with toast and fruit. On February 27, 2024, LPA observed residents eating lunch which included a taco, with ground beef, tomatoes, onions and cilantro. Residents were also offered Jello, water and juice.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

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END OF REPORT.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 9

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: 5	DATE:	04/11/2024
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator Dieu-qui H Nguyen		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Administrator does not spend a sufficient amount of time in the facility

INVESTIGATION FINDINGS:

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On October 11, 2021, the Department received a complaint alleging Administrator does not spend a sufficient amount of time in the facility.

On October 12 & 14, 2021 and January 11 & 13, 2024, the Department interviewed residents, R1-R5. 3 Out of 5 residents stated the ADM was seen working at least 3x a week but could not confirm how many hours the ADM stayed when he/she worked. The remaining 2 Out of 5 residents interviewed stated they did not want to be interviewed.

On January 11, 2024, LPA Monter arrived to the facility at 11:10am. LPA observed the ADM was not in the facility and requested to staff to call the ADM. The ADM was informed that the LPA was at the home for an annual inspection and a complaint investigation. LPA observed the ADM arrive at the facility around 1:00pm, that same day.

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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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

LIC9099 (FAS) - (06/04)

Page: 6 of 9

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: 04/11/2024

NARRATIVE

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On February 27, 2024, LPA Monter arrived to the facility at 1:00pm. LPA observed the ADM was not in the facility. LPA interviewed 3 Out of 3 staff. 2 Out of 3 staff interviewed stated the ADM did not come to the facility on 02/27/2024, 02/26/2024 and 02/25/2024.

On March 12, 2024, LPA Simi Rai conducted an unannounced complaint investigation to open a new complaint. LPA Rai arrived at the facility at 9:00am. Facility staff contacted ADM, who stated he/she is in Sunnyvale and would take 30-40 minutes to arrive. LPA Rai concluded her visit at 11:40am and the ADM did not arrive during LPA’s visit.

On April 3, 2024, LPA Monter interviewed facility ADM. ADM stated she does have a part time job doing assessments and consulting. ADM stated the hours she works are as needed basis. ADM stated she does come to the facility, but her hours are variable, as she has to go when she needs to do an assessment. When asked how many hours per day she works at the facility Monday-Friday, 8am-5pm, ADM responded at least 3 hours.

Based on a review of ADM’s Resume and Applicant information, the ADM works for Vista Verde Home Care from July 1, 2014 to present. Under duties, the Applicant information form states ADM conducts 1:1 care of seniors in their homes.

On September 20, 2022, the Department was informed by the Licensee/Administrator when asked if he/she holds a fulltime employment other than overseeing this RCFE facility. In reply, he/she confirmed that he/she does assessment and 1:1 transportation to appointments Monday to Thursday. Licensee/Administrator stated he/she is on duty Friday to Sunday. Licensee sent a LIC500, dated September 20, 2022, which states, he/she works Wednesday thru Sunday, 8am-7pm.

The Department has investigated the above allegation. Based on interviews conducted, and records reviewed, 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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 9

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: 04/11/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/12/2024 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (a) All … The administrator shall … shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility … fulfill his/her responsibilities ... This requirement was not met as evidence by:	1 2 3 4 5 6 7	ADM stated she will send a written plan of action on how she will ensure she is at the facility 20 hours a week, Monday-Friday, during working hours, 8am-5pm.
	8 9 10 11 12 13 14	Based on record reviews and interviews conducted, the ADM is not spending 20 hours a week in the facility Monday-Friday, during working hours, 8am-5pm. This poses an immideate safety and health risk to residents in care.	8 9 10 11 12 13 14	ADM stated she will send the written plan of action by POC date April 12, 2024
	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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

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