019200506-12-30-2021-15-AS-KHOS-CE6G4V-20220506050119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200506
Report Date: 12/30/2021
Date Signed: 12/30/2021 12:08:09 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
02/18/2020 and conducted by Evaluator Gregory Clark

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200218094628

FACILITY NAME:	HERITAGE HAVEN		FACILITY NUMBER:	019200506
ADMINISTRATOR:	FERDINAND GUTIERREZ		FACILITY TYPE:	740
ADDRESS:	389 JUANA AVENUE		TELEPHONE:	(510) 357-1300
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	27	CENSUS: 18	DATE:	12/30/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Ferdinand Gutierrez, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility is dirty.
Residents had a strong odor.
Facility staff did not seek timely medical attention resulting in hospitalization of resident.

INVESTIGATION FINDINGS:

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On 12/30/2021 LPA G. Clark and LPM Y. Flores-Larios arrived unannounced to deliver compliant findings. LPA and LPM met with Jhemierly Morales, Caregiver. Ferdinand Gutierrez, administrator arrived shortly after.

On 10/27/2021, LPA L. Fontanilla reviewed annual inspection report conducted at the facility on 2/20/2020.
Based on the report, LPAs observed cobwebs in the hallway and dust/grease/web on a sprinkle on top of the stove. Based on interview conducted with one of the LPAs who conducted the visit, there were parts of the facility (hallway and kitchen) that were observed with dust and cobwebs. However, LPA states that the whole facility did not seem dirty.

LPA interviewed S2 and S3 who both said that the facility gets cleaned by a staff. However, due to the other responsibilities that staff need to perform like cooking, doing laundry and assist residents if needed, they are not able to clean the facility thoroughly due to lack of time.

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200218094628

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 HAVEN	FACILITY NUMBER: 019200506
	VISIT DATE: 12/30/2021

NARRATIVE

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Based on interviews conducted and records reviewed, the above allegation is Unsubstantiated.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Based on interviews conducted by LPA, Administrator states there are residents who refuse to take showers or clean themselves up. Administrator states that staff can only encourage residents but if they refuse, staff cannot force them to take showers. S2 and S3 state that the odor at the facility comes from the residents who refuse to take showers.

Based on interviews conducted, the above allegation is Unsubstantiated.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

On 9/23/2021, LPA L. Fontanilla interviewed Administrator via telephone regarding R1’s hospitalization. Administrator denied knowing that R1 was hospitalized. Administrator states he was not informed by the staff. During the interview, Administrator asked S2 if R1 was hospitalized. S2 confirmed with Administrator that R1 was hospitalized. However, Administrator states he does not have a copy of the discharge summary.
On 11/3/2021, LPA contacted RP to find out if RP has a copy of the discharge papers. RP states RP does not have a copy of the discharge papers. LPA asked RP how R1 came back to the facility. RP states R1 might have been brought back to the facility by an ambulance.

On 11/4/2021, LPA interviewed R1 by telephone. R1 remembers being sick and being in the hospital in February 2020. R1 also mentioned about staying in a convalescent home for two weeks to recover. However, R1 does not remember which hospital he went to, the diagnosis and getting any discharge papers.

LPA is not able to obtain hospitalization records due to facility’s failure to provide LPA with R1’s discharge papers. R1 and R1’s family also did not have any records of R1’s discharge papers.

Based on interviews conducted, the above allegation is Unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

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

LIC9099 (FAS) - (06/04)

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