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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601095
Report Date: 12/10/2021
Date Signed: 12/10/2021 12:27:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HERITAGE ESTATESFACILITY NUMBER:
015601095
ADMINISTRATOR:BATTISTI, STEVEFACILITY TYPE:
740
ADDRESS:900 E STANLEY BLVDTELEPHONE:
(925) 373-3636
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:65CENSUS: 51DATE:
12/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Steve Battisti, Executive DirectorTIME COMPLETED:
12:40 PM
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On 12/10/2021 at 10:35AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 12/2/2021. LPA met with Executive Director, Steve Battisti and explained the reason for the visit.

Death report dated 12/7/2021 stated that R1 was found face first on ground beside the bed. Staff called 911 and CPR was performed prior to ambulance's arrival.

During visit, LPA reviewed R1's file and observed R1 was independent. According to physician's report dated 7/25/2020, some of R1's diagnosis include diabetes, hypertension, atherosclerosis of Aorta, and depression. LPA interviewed staff and revealed that action was taken right away and staff called 911. While on the phone with 911, chest compressions was performed on R1 until paramedics arrived.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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