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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202753
Report Date: 08/08/2024
Date Signed: 08/08/2024 03:43:11 PM


Document Has Been Signed on 08/08/2024 03:43 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:NGUYEN, DIEU-QUI HFACILITY TYPE:
740
ADDRESS:1021 HEATHERFIELD LANETELEPHONE:
(408) 621-9887
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:9CENSUS: 5DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator Qui NguyenTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Qui Nguyen. During the visit, LPA observed 5 residents, 1 staff and 1 volunteer. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the facility backyard. LPA's observed the facility sheds. LPA observed that behind the shed, closest to the deck, had several tools and a red container of gasoline. (Photograph was taken.) ADM put the tools inside the shed during the visit. LPA's also observed behind the shed closest exit #3 had a container of lighter fluid. LPA's also observed in the facility backyard between both sheds had several dog droppings. LPA's also observed an assortment of wheelchairs, walkers in the deck. ADM stated she plans to move them to storage.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 78 degrees F, and hot water temperature was measured at 119 degrees F in both resident bathrooms.

Fire extinguisher was serviced in July 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on July 9, 2024.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 712-2018
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/08/2024
NARRATIVE
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During the tour of the facility, LPA observed residents bedrooms. LPA observed 4 Out of 5 residents beds had half side rails. LPA requested to see the doctors orders for the bed rails. ADM stated she didn't know she had to get a doctors order for the half side bed rails.

LPA reviewed facility records for 3 residents. Resident R2 and R3 have a neurocognitive disorder. R2 physician's report is dated January 25, 2023 and Needs & services plan is date February 7, 2023. R3's physician's report is dated November 5, 2019 and Needs & Services plan is dated June 21, 2023.

LPA reviewed 3 resident medications and centrally stored medication records. LPA's reviewed medication by cross referencing the centrally stored medication record and comparing that information with the medication bottles. While reviewing resident R2's medication bottles; LPA's observed that 4 medication bottles were not listed in the centrally stored medication log. While reviewing resident R1's medication bottles; LPA's observed 1 medication bottle was not listed on the centrally stored medication records. LPA's also observed 3 medication that had incorrect information imputed in the centrally stored medication record.

LPA reviewed 3 staff records. LPA's requested to review V1's health statement & Health screening documents. ADM stated she does not have V1's health statement & health screening documents. LPA conducted interviews with 2 staff and 2 residents.

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Qui Nguyen and a copy of the signed report was provided. Appeal rights were provided.

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END OF REPORT.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 712-2018
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/08/2024 03:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed that behind the shed, closest to the deck, had several tools and a red container of gasoline. LPA's also observed behind the shed closest exit #3 had a container of lighter fluid. This poses an immediate health, safety or personal rights risk to persons in care
POC Due Date: 08/09/2024
Plan of Correction
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Administrator moved Toxic materials and tools secured them into the locked toolshed during visit. ADM stated she will send a letter of understanding regarding the regulation. ADM will sent to LPA by POC date, August 9, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 08/08/2024 03:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA's observed in the facility backyard between both sheds had several dog droppings. ADM stated residents have activity's in the backyard as well. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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ADM stated she will send a written plan of action on how she will ensure The facility remains clean, safe, sanitary and in good repair at all times. ADM stated she will send the written plan of action, to LPA by POC date, August 15, 2024.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above. LPA observed 4 Out of 5 residents beds had half side rails. LPA requested to see the doctors orders for the bed rails. ADM stated she didn't know she had to get a doctors order for the half side bed rails. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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ADM stated she will get a doctors order for the bed rails. ADM stated she will send documentation orders have been made and will be sent to LPA by POC date, August 15, 2024.
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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 08/08/2024 03:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview , the licensee did not comply with the section cited above. Resident R2 & R3 have a neurocognitive disorder. R2 physician's report is dated January 25, 2023 and Needs & services plan is date February 7, 2023. R3's physician's report is dated November 5, 2019 and Needs & Services plan is dated June 21, 2023. ADM stated she does not have updated forms. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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ADM stated she will send to LPA documentation showing resident R2 & R3's Medical Assessment, and a reappraisal has been updated. ADM stated she will send the documentation by POC date, August 15, 2024.
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. R2's had 4 medication bottles were not listed in the centrally stored medication log. R1 had 1 medication bottle was not listed on the centrally stored medication records. R1 had 3 medications that had incorrect information imputed in the centrally stored medication record. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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ADM stated she will send a letter of understanding regarding the regulation and the importance of maintaining an accurate centrally stored medication record. ADM stated she will send the letter to LPA by POC date, August 15, 2024.
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 ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 08/08/2024 03:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(b)(1)(2)
87412 Personnel Records (b) Personnel records shall be maintained for all volunteers and shall contain the following: (1) A health statement as specified in Section 87411(f). (2) Health screening documents as specified in Section 87411(f)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA's requested to review V1's health statement & Health screening documents. ADM stated she does not have V1's health statement & health screening documents. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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ADM stated she will send LPA copy of V1's health statement & Health screening documents. ADM stated she will send to LPA by POC date, August 15, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 712-2018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6