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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601095
Report Date: 12/27/2024
Date Signed: 12/27/2024 05:53:48 PM

Document Has Been Signed on 12/27/2024 05:53 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HERITAGE ESTATESFACILITY NUMBER:
015601095
ADMINISTRATOR/
DIRECTOR:		SUSAN DONAGHYFACILITY TYPE:
740
ADDRESS:900 E STANLEY BLVDTELEPHONE:
(925) 373-3636
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 65CENSUS: 59DATE:
12/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:00 PM
MET WITH:Michael Fillari, General ManagerTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 12/27/2024 at 5:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with General Manager, Michael Fillari and explained the purpose for the visit.

While LPA G. Luk was at the facility for a complaint investigation (#15-AS-20240213095509), the following deficiency was observed.

During the complaint investigation, LPA observed the call button response time shows there were several incidents where the resident waited more than 30 minutes for staff assistance. Interview with staff and residents revealed that the facility is short staff resulting in residents waiting longer for staff assistance. It was noted that wait time can be 20-40 minutes for staff to respond to call button.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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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Document Has Been Signed on 12/27/2024 05:53 PM - It Cannot Be Edited


Created By: Grace Luk On 12/27/2024 at 05:27 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HERITAGE ESTATES
FACILITY NUMBER: 015601095

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2025
Section Cited
CCR
87411(a)

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Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers...to provide the services necessary...In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...
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General Manager (GM) has agreed to provide a written plan to address the long response time for call button. GM will submit the written plan to CCLD by POC date.
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Based on investigation, the licensee did not comply with the section cited above by not responding to call button in a timely manner which poses a potential health and safety risk to the residents in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
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