Heritage Inn

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 7 client bedrooms, a staff bedroom, 5 full bathrooms, one half bathroom, kitchen, living, dining rooms and small office. There is a fenced backyard and detached 2 car garage--used for storage--plus an adjacent enclosed storage room. Washer and dryer are located near kitchen. No accessible bodies of water or fire safety hazards observed. Medications are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars, nonskid flooring material, hand washing reminder signs, and liquid soap. Hot water temperature is tested at 111 degrees in rear bathroom. First-aid kit is inspected and complete. There are 4 staff present. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as required staff records and first-aid training. Ms. Padoina, Katie Eiseman and Tom Eiseman are certified RCFE administrators (x 4/27, 1/27, 4/26) that oversee facility operations. Some client files are reviewed and Centrally Stored Medications REcords are reviewed. Deficiencies of the California Code of Regulations, Title 22, are cited on following pages.the state’s words, verbatim · CDSS document, Aug 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Aug 28, 2025

STORAGE SPACE ... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met, as large container of purple cleaning liquid "Flash" is stored in front client bathroom, accessible to clients. Licensee failed to ensure that cleaning liquids are stored where items are not accessible to clients. This posed an immediate health & safety risk to clients.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Liquid "Flash" was removed from clients' bathroom in LPA's presence and stored in office, which is inaccessible to clients. Deficiency corrected and cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(4) · Plan of correction due date: Sep 5, 2025

INCIDENTAL MEDICAL CARE All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met, as there is no Rx label for Myrbetriq for client #5. Rx number is recorded on Centrally Stored Medications Record. Licensee failed to ensure that RX medications are labeled by pharmacy, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE.

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 8 client bedrooms, 5 bathrooms, kitchen, living, and dining rooms. There is a fenced backyard and detached 2 car garage, used for storage. Washer and dryer are located near kitchen. No accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars, nonskid flooring material, hand washing reminder signs, and liquid soap. Hot water temperature is tested at 113 degrees in rear bathroom. First-aid kit is inspected and complete. There are 3 staff present. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, and first-aid training is checked. Katie Eiseman is a certified RCFE administrator (x 1/25) that oversees facility operations. Some client files are reviewed. Per staff, clients #1 and #2 tested positive for COVID. COVID was not reported as required to CCLD, nor San Mateo County Public Health Department. There is no record of when clients were COVID tested. There are no N95 respirators maintained, and only a handful of KN95 masks are available, per staff. Roomwhere COVID clients reside are not identified with appropriate COVID signage nor are there PPE carts outside of rooms. There are 3 staff on site; none are wearing N95 or KN95 masks. There are only 3 small bottles of hand sanitizer on site--all with an inch or less of product in the bottom of bottles. There is an ample supply of isolation gowns in the garage storeroom and boxes of gloves are stored in kitchen and clients' rooms. Deficiencies of the California Code of Regulations, Title 22, are cited on following pages. The following updated form is requested to be submitted to CCLD BY 8/29/24: • LIC 610 Emergency Disaster Plan (9 pages, signed and dated)the state’s words, verbatim · CDSS document, Aug 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(6) · Plan of correction due date: Aug 23, 2024

BASIC SERVICES Basic services shall at a minimum include: Arrangements to meet health needs.... as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met, as licensee failed to ensure an adequate supply of personal protective equipment (PPE)--N95 masks--is maintained to ensure the safety of staff and residents when COVID infections are present in facility. This poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: During LPA's visit, administrator arrived with PPE--box of 16.9 oz. bottles of hand sanitizers, 5 N95 respirators, KN95 masks, isolation gowns. Additional supply of N95 respirators must be maintained. Plan/proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(a) · Plan of correction due date: Aug 23, 2024

REPORTING REQUIREMENTS A written report shall be submitted to the licensing agency... within 7 days of the occurrence of any incident which threatens the welfare, safety or health of any resident... report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment... This requirement was not met, as licensee failed to submit written report of 2 COVID clients to CCLD AND County Public Health Dept. This posed an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Copy of COVID Incident Report for client #1 is given to LPA today. Plan/proof of correction to be submitted to CCLD BY DUE DATE, and shall include written reports of COVID, including staff and client who tested postive during LPA's visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(2)(C) · Plan of correction due date: Aug 23, 2024

INFECTION CONTROL REQRMENTS The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter. This requirement was not met, as staff are observed in facility wearing surgical masks only, even when assisting client #1 in hallway, who was identified as COVID positive. Licensee failed to ensure that caregivers in direct contact with COVID clients are trained in proper use of PPE , which poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Plan/proof of correction to be submitted to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(1) · Plan of correction due date: Aug 23, 2024

CRIMINAL RECORD CLEARANCE All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, obtain a CA clearance or a criminal record exemption as required by the Department. This requirement is not met, as staff CC started in May & does not have criminal record clearance. Licensee failed to ensure that staff with direct client contact maintain criminal record clearance and assocation with facility, which poses an immediate health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Staff CC shall not have direct contact with clients unless and until criminal record clearance is associated to facility. Civil penalty of $500 is assessed. Proof of correction to be submitted to CCLD BY DUE DATE. Failure to comply may result in civil penalty assessment.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: Aug 23, 2024

GENERAL FOOD SERVICE Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met, as there are only 5 cans of fruit maintained for 7-day non-perishable supply. There are no canned vegetables nor protein maintained. Licensee failed to ensure an adequate 7-day supply of canned foods, which poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Proof/plan of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Aug 29, 2024

PERSONNEL REQUIREMENTS--GENL Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met, as 2 out of 6 staff do not have current 1st aid training. Licensee failed to ensure that staff who provide client care have current 1st aid training, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Proof of current first-aid training for staff DJS and JLC will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.311 · Plan of correction due date: Aug 23, 2024

HEALTH AND SAFETY CODE Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8. This requirement is not met, as there is no carbon monoxide detector in facility. Licensee failed to ensure that carbon monoxide detector is maintained in facility, which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Carbon monoxide detector will be installed and operable, and proof/plan of correction to be sent to CCLD BY DUE DATE.