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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600805
Report Date: 09/19/2024
Date Signed: 09/19/2024 04:20:10 PM

Document Has Been Signed on 09/19/2024 04:20 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HEIRLOOM GARDENS OF DALY CITYFACILITY NUMBER:
415600805
ADMINISTRATOR/
DIRECTOR:		DE LA TORRE, JOCELYNFACILITY TYPE:
740
ADDRESS:75 SURREY COURTTELEPHONE:
(650) 922-1039
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 6DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Julieta Jornales and Kervin OngTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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On September 19, 2024, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility at 12:50 PM to conduct the Annual 1-year required inspection. LPAs met with Julieta Jornales Biagi, House Manager and Kervin Ong, Caregiver, and explained the purpose of the visit.

LPA toured the physical plant and observed it to be clean and odor-free at a comfortable temperature. This is a two-story building with 5 resident bedrooms, 2 bathrooms, and a kitchen with dining on the first level. The second level has 1 resident room, 2 staff rooms, and 2 bathrooms. The attached garage on the first floor was observed to have a washer and dryer for laundry and extra food supply storage.

3 exit doors were observed at the facility. Auditory devices to monitor exits were observed to be operational. All exits and walkways were found to be unobstructed and clutter-free. No accessible bodies of water or fire safety/tripping hazards were observed. The fire extinguisher was fully charged and last serviced on 02/12/2023. The smoke detector and carbon monoxide detector were fully operational.

All rooms were observed to be clean with the required furniture and sufficient lighting. At 1:26 PM, LPA observed a bathroom cleaner placed on a side table in Resident room #3, which poses immediate health risk to the person in care. The bathrooms were observed to be clean and equipped with non-skid mats, trash cans, grab bars, liquid soap, and paper towels. At 1:35 PM, LPA observed Toilet bowl cleaner was observed near the sink in resident's bathroom, which poses immediate health risk to the person in care. At 1:40 PM, the hot water temperature was measured in the residents bathroom sink at 131.9°F, which poses immediate health risk to the person in care.

At 1:52 PM, LPA observed toxins, cleaning supplies, and sharp objects were not stored/locked properly in the kitchen and accessible to the residents, which poses immediate health risk to the person in care. At 1:58 PM, LPA inspected the refrigerator and observed expired milk dated 09/14, which poses immediate health risk to the person in care. The facility had the required 7 days of non-perishables and 2 days of perishables.



LPA reviewed five resident records and four staff records. All were observed to be complete.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 09/19/2024 04:20 PM - It Cannot Be Edited


Created By: Kiran Jain On 09/19/2024 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HEIRLOOM GARDENS OF DALY CITY
FACILITY NUMBER: 415600805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation the licensee did not comply with the section cited above in 1 out of 2 bathrooms. LPA measured the hot water temperature in the residents bathroom sink at 131.9°F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Licensee/Administrator shall submit a plan in writing on how to address this deficiency by the POC due date.
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 by not keeping cleaning supplies, chemical, and sharp objects locked and inaccessible to the residents. LPA observed dishwashing solution and knife on kitchen countertop. Scissor and knives were observed to be stored in an unlocked kitchen cabinet drawer. Toilet bowl cleaner was observed near the sink in resident's bathroom. Bathroom cleaner was observed in Resident room #3, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Licensee/Administrator shall submit a plan in writing on how to address this deficiency by the POC due date.
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:April Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/19/2024 04:20 PM - It Cannot Be Edited


Created By: Kiran Jain On 09/19/2024 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HEIRLOOM GARDENS OF DALY CITY
FACILITY NUMBER: 415600805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 expired milk dated September 14 stored in the kitchen refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Licensee/Administrator shall submit a plan in writing on how to address this deficiency by the POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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3
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:April Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/19/2024 04:20 PM - It Cannot Be Edited


Created By: Kiran Jain On 09/19/2024 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HEIRLOOM GARDENS OF DALY CITY
FACILITY NUMBER: 415600805

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review and interview, the licensee did not comply with the section cited above as the facility did not conduct fire drills at least once a quarter.Emergency drills are not conducted in the facility and there were no emergency drill logs available for LPA to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee/Administrator shall submit a plan in writing on how to address this deficiency by the POC due date.
Section Cited
Deficient Practice Statement
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4
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:April Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HEIRLOOM GARDENS OF DALY CITY
FACILITY NUMBER: 415600805
VISIT DATE: 09/19/2024
NARRATIVE
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At 2:50 PM, during the facility file/documentation review, there were no emergency drill logs available for LPA to review. Based on the interview with the staff, emergency drills are not conducted in the facility, which poses potential health risk to the person in care.

The resident’s medications are securely stored in a locked cabinet. Medication administration records (MARs) were reviewed, and no expired medications were observed. The First Aid kit was checked and observed to be complete.

The following updated forms are requested to be submitted to CCLD by 09/26/2024:


· LIC 500: Personnel Report
· LIC 308: Designation of Facility Responsibility
· Administrator Certificate
· First Aid Certificate(s)
· Liability Insurance

The deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted. This report was reviewed with Julieta Jornales Biagi, House Manager and Kervin Ong, Caregiver, and a copy of this report along with appeal rights was left at the facility.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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