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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601095
Report Date: 12/18/2023
Date Signed: 12/18/2023 01:23:09 PM

Unfounded


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
12/14/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231214155404
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: 58DATE:
12/18/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Michael Fillari, General ManagerTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff physically abused resident at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/18/2023 at 10:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings regarding the allegation above. LPA met with General Manager, Michael Fillari and informed him of the reason for the visit.

During the course of investigation, LPA interviewed resident, staff, and witness. LPA obtained and reviewed documents including physician's report, care plan, and POA documents. Interview with resident and witness revealed the caregiver that hit R1 was from an outside agency and was not a facility caregiver. W1 stated that the caregiver was hired by R1's POA and is a private caregiver for R1 only. The Department will cross report to appropriate agency.

This agency has investigated the complaint allegation. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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