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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015650006
Report Date: 12/15/2022
Date Signed: 12/16/2022 09:33:32 AM


Document Has Been Signed on 12/16/2022 09:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HEIWA HOUSEFACILITY NUMBER:
015650006
ADMINISTRATOR:ONO, YUKAFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:6CENSUS: 0DATE:
12/15/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Yuka Ono, Melinda Kakalia, Anthony Mongomery, Lilibeth TocoTIME COMPLETED:
02:45 PM
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On 12/15/22 at 1:00 PM, CCL met with Regional Center and listed facility for an Informal Meeting. The meeting was held at 2580 North First Street Suite 350, San Jose, CA 95131. The following attended the meeting;

CCL: Alyssa Ng - Licensing Program Analyst (LPA) , Carolyn Flynn and Isabel Mendoza - Licensing Program Manager (LPM)

Regional Center: Derrick Levingston - Quality Assurance Specialist (QA), Mike Minton - Quality Assurance Supervisor, Kimberly Limato- Case Manager Supervisor

Heiwa House: Yuka Ono - Administrator, Melinda Kakalia - Facility Manager, Anthony Montgomery- Manager, Lilabeth Toco -Assistant Administrator


Topics that were discussed:

Lack of supervision: CCL discussed the pattern of allegations regarding unexplained injuries and the one on one supervision.

Reporting requirements: CCL explained the importance of reporting incidences on time. Regional Center discussed missing incident reports. CCL requested all incident reports for the month of November- Present.

-----CONT. ON 809C----
SUPERVISOR'S NAME: Helga WongTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Alyssa NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HEIWA HOUSE
FACILITY NUMBER: 015650006
VISIT DATE: 12/15/2022
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Buildings and Grounds:

CCL brought up concerns regarding a twin bed for a client who is 6 foot. LPA Ng showed pictures of one of the clients headboard. There is chipping and wooden chips hanging out.

Administrator Yuka stated that they have a maintenance person who can do repairs when called. CCL recommended to have a maintenance log.

Personal Rights:

LPA Ng discussed the concerns of bald spots due to improper brushing and care and wanted to discuss the wooden play structure in the home. Regional Center also had concerns with the supervision and what clients can.are doing inside of the structure unsupervised.

Concerns about Administrator:

CCL had some concerns regarding the hours of the Administrator. CCL requested to have Administrator present during business hours.


A new LIC500 will be sent to CCL that will reflect the hours of the Administrator and will reflect proper supervision with one on one clients.


No deficiences were cited. Technical Support Program (TSP) was offered. LPM Carolyn Flynn set the due date for December 23rd 2022 if listed facility wants/needs TSP. The Licensee was also cautioned that if there are continued concerns for similar issues, the licensee could be referred to a Non-Compliance Conference for further action.
SUPERVISOR'S NAME: Helga WongTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Alyssa NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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