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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202753
Report Date: 08/28/2025
Date Signed: 08/28/2025 05:32:55 PM

Document Has Been Signed on 08/28/2025 05:32 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HEATHERFIELD INNFACILITY NUMBER:
435202753
ADMINISTRATOR/
DIRECTOR:		NGUYEN, DIEU-QUI HFACILITY TYPE:
740
ADDRESS:1021 HEATHERFIELD LANETELEPHONE:
(408) 621-9887
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 9CENSUS: 4DATE:
08/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Dieu-Qui NguyenTIME VISIT/
INSPECTION COMPLETED:
12:56 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Dieu-Qui Nguyen. LPA observed 4 residents (R1-R4). 2 staff (S1-S2) and two volunteer (V1, V2). S1 stated ADM comes to facility every day and usually stays 6 hours. ADM arrived the facility about one hour after LPA arrived at the facility. V1 and V2 are not associated with the facility.

LPA toured the facility inside and out with S1 License, Administrator Certificate, and personal rights posters were observed in the facility. LPA reviewed 2 resident file and 2 staff files. 1 out of 2 staff file was observed missing staff training log, ADM stated he/she has that at home, ADM stated to send to LPA by end of today.

Family room, kitchen, dining area, 3 restrooms, a office area, a staff room, 5 resident rooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet was observed locked. Knives closet, and dish washing soap closet were observed unlocked. S1 stated staff were just using it. S1 locked the knives closet and dish washing soap closet immediately. Room temperature was at 76 degree F, and hot water temperature was at 119 degree F in facility. Fire extinguisher was expired, ADM stated the facility will install new one today. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested by S1, and were working. First aid box, night lights, and flash lights were observed in the facility. The screens in a resident room, and a bathroom.

Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: HEATHERFIELD INN
FACILITY NUMBER: 435202753
VISIT DATE: 08/28/2025
NARRATIVE
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Front yard and backyard were inspected. 2 storage room was observed at backyard. The last time the facility conducted the emergency and fire drill was on 7/15/2025.

Deficiency noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.


Page 2.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/28/2025 05:32 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 08/28/2025 at 01:11 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HEATHERFIELD INN
FACILITY NUMBER: 435202753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 in that the fire extinguisher was observed expired which poses an immediate safety risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Administrator agree to send plan of correction by the POC due date and to install new fire extinguisher immediately.
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) 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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that two volunteers were observed helping residents in the facility without association with the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Administrator agree to send plan of correction by the POC due date and to associate the two volunteers with the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Chihhsien Chang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/28/2025 05:32 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 08/28/2025 at 01:11 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: HEATHERFIELD INN
FACILITY NUMBER: 435202753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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 in that the window screens in a resident room and in a bathroom were oberved needed to repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
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Administrator agrees to send plan of correction by the POC due date and to repair the window screens.
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 2 out 2 residents' centrally stored medication forms were observed inaccurate which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
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Administrator agrees to send plan of correction by the POC due date and to provide staffing for medication to ensure the centrally stored medication forms are maintained accurate.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Chihhsien Chang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
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