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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005194
Report Date: 06/02/2021
Date Signed: 06/04/2021 07:17:04 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HERITAGE HOMEFACILITY NUMBER:
507005194
ADMINISTRATOR:ROBERT L. IRWIN, JR.FACILITY TYPE:
740
ADDRESS:943 TERRACE COURTTELEPHONE:
(209) 845-2712
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:6CENSUS: 4DATE:
06/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:ADMINISTRATOR - AMY IRWINTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA's) Sarah Hurt and Ruth Wallace conducted an unannounced visit today to annual inspection. LPA's met with Administrator Amy Irwin. Continual Administrator's Certification expires September 30, 2021. There are currently 4 residents who reside at this home and there is one resident on hospice at this time. LPA'S inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguishers expire 11/9/2021. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 112.2 F degrees. First Aid kit is on site and complete. Toxins are locked.

This facility is operating within the scope of their license. LPA's reviewed 2 resident files. Resident's medical files and medications were reviewed. All resident files review were in compliance Three staff files reviewed and each had the required criminal record clearances. First Aid and CPR training for was current and staff has current training

No deficiencies were identified on this inspection.

The administrator shall send in updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-D the Emergency Disaster Plan if needed and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator and copy of report left at facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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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