Heritage Inn

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.

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)

LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 8 client bedrooms and 5 full and one half bathroom, kitchen, living, and dining rooms; there is no staff room. There is an enclosed backyard and detached 2-car garage, which is used for storage. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is inspected. 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 and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 9 residents present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Annie De La Cruz is a certified RCFE administrator (x 11/21) that oversees facility operations. The following updated forms/information are requested to be submitted to CCLD BY 11/24/21: • Proof of high school graduation or college of administrator designee • Current liability insurance • LIC 500 Personnel Report • LIC 309 Administrative Organization • LIC 610 Emergency Disaster Plan • LIC 400 Affidavit Regarding Client Cash Resources Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. See Technical Advisory Notes for additional information.