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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200506
Report Date: 12/30/2021
Date Signed: 12/30/2021 12:04:32 PM

Document Has Been Signed on 12/30/2021 12:04 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 HAVENFACILITY NUMBER:
019200506
ADMINISTRATOR:FERDINAND GUTIERREZFACILITY TYPE:
740
ADDRESS:389 JUANA AVENUETELEPHONE:
(510) 357-1300
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 27CENSUS: 18DATE:
12/30/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Ferndinand Guitierrez, AdministratorTIME COMPLETED:
12:15 PM
NARRATIVE
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On 12/30/2021 LPA G. Clark and LPM Y. Flores-Larios arrived unannounced to conduct a case management visit related to information received for complaint #15-AS-202001128094628. LPA and LPM met with Jhemierly Morales, Caregiver. Ferdinand Gutierrez, administrator arrived shortly after.

On 9/23/2021 while conducting interview with Administrator, Administrator denied knowing that R1 was hospitalized in February 2020. R1 states that nobody told him about R1’s hospitalization. Administrator also informed LPA that he does not have any hospital discharge on file for R1. Administrator states that the facility only admits residents who are independent.

During the telephone interview, Administrator asked S2 if R1 was hospital. S2 confirmed with Administrator that R1 was indeed hospitalized in February 2020.

The following deficiencies are being cited (see LIC 809D) from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report was provided to Administrator

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2021
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 2
Document Has Been Signed on 12/30/2021 12:04 PM - It Cannot Be Edited


Created By: Gregory Clark On 12/30/2021 at 11:12 AM
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 HAVEN
FACILITY NUMBER: 019200506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2021
Section Cited
CCR
87405(d)(1)

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 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7).
(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Administrator states he will submit plans to CCL on how to ensure that all residents are provided the appropriate supervision needed by POC date.
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This requirement is not met as evidenced by: Based on interview conducted, Administrator was not aware that R1 was hospitalized in February 2020 until the phone interview conducted by LPA on 9/23/2021 which poses an immediate risk to health and safety of clients under care.
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Type B
01/06/2022
Section Cited
CCR87405(d)(3)

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Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7).
(3) Ability to maintain or supervise the maintenance of financial and other records.
This requirement is not met as evidenced by:
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By POC date, Administrator will review Sec 87506 - Resident Records and submit self-certification stating understanding of the requirements of the section.
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Based on interview conducted on 9/23/2021, Administrator states he does not have R1’s discharge papers from hospitalization on February 2020 which poses a potential risk to the health and safety of client under 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Gregory Clark
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2021


LIC809 (FAS) - (06/04)
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