<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601095
Report Date: 02/26/2025
Date Signed: 02/26/2025 05:18:00 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250224143819
FACILITY NAME:HERITAGE ESTATESFACILITY NUMBER:
015601095
ADMINISTRATOR:SUSAN DONAGHYFACILITY TYPE:
740
ADDRESS:900 E STANLEY BLVDTELEPHONE:
(925) 373-3636
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:65CENSUS: 59DATE:
02/26/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Susan Donaghy, Health and Wellness DirectorTIME COMPLETED:
05:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medication
Staff did not notify resident's authorized representatives of incidents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/26/2025 at 1:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegations above. LPA met with Health and Wellness Director, Susan Donaghy and explained the purpose of the visit.

During the investigation, LPA interviewed staff and complainant. LPA reviewed and obtained documents including email correspondence, emergency information, care plan, care notes, MAR (Medication Administration Record), resident incident reports, hospice information, and death report.

Staff mismanaged resident's medication
After reviewing a sample of residents' MAR, LPA observed the residents were prescribed Tamiflu after being diagnosed with influenza. Doctor's order indicated that Tamiflu medication should be given 1 capsule by mouth 2 times a day for 5 days. Resident's MAR revealed that medication was given accordingly.
(continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 15-AS-20250224143819
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HERITAGE ESTATES
FACILITY NUMBER: 015601095
VISIT DATE: 02/26/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff did not notify resident's authorized representatives of incidents
Interview with complainant indicated that family was not notified when R2 was sick. However, LPA observed facility's resident incident report documented that R2's family was notified when R2 had influenza.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250224143819

FACILITY NAME:HERITAGE ESTATESFACILITY NUMBER:
015601095
ADMINISTRATOR:SUSAN DONAGHYFACILITY TYPE:
740
ADDRESS:900 E STANLEY BLVDTELEPHONE:
(925) 373-3636
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:65CENSUS: 59DATE:
02/26/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Susan Donaghy, Health and Wellness DirectorTIME COMPLETED:
05:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident died due to staff neglect
Staff are not following infectious control procedures
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/26/2025 at 1:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegations above. LPA met with Health and Wellness Director, Susan Donaghy and explained the purpose of the visit.

During the investigation, LPA interviewed staff and complainant. LPA reviewed and obtained documents including email correspondence, emergency information, care plan, care notes, MAR (Medication Administration Record), resident incident reports, hospice information, and death report.

Resident died due to staff neglect
Interview with complainant indicated R4 passed away last week and R4 was sick. Interview with staff revealed that R4 was on hospice care and did not have influenza prior to passing away. Facility notified CCLD when R4 went on hospice care on 2/15/2025 and when R4 passed away.
(continue on LIC9099C...)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20250224143819
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HERITAGE ESTATES
FACILITY NUMBER: 015601095
VISIT DATE: 02/26/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff are not following infectious control procedures
Interview with complainant indicated that facility did not follow infectious control procedures by not notifying family members. However, LPA observed facility's resident incident reports revealed that residents' families were notified. Facility notified CCLD and health department via email. LPA observed one resident was in isolation and facility had PPEs, garbage can, and signage in front of the resident's room.

This agency has investigated the complaint allegations. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4