019200506-5-27-2026-15-AS-BFOG-DU3QVB-20260514123002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200506
Report Date: 04/28/2026
Date Signed: 05/27/2026 06:11:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
04/01/2026 and conducted by Evaluator Yasamin Brown

COMPLAINT CONTROL NUMBER: 15-AS-20260401142902

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: 19	DATE:	04/28/2026
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Ferdinand Gutierrez, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff are not providing adequate supervision to the residents in care.

INVESTIGATION FINDINGS:

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***This is an amended report from visit on 4/28/2026***

On 4/28/2026 at 9:25 AM, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Ferdinand G, Administrator and explained the purpose of the visit.

During the course of investigation, LPA obtained the following documents for R1: LIC602 (Medical Assessment), Identification and Emergency Contact, Functional Capability and Appraisal Needs and Services Plan. LPA obtained the following documents: Resident Roster and the LIC500 (Personnel Report). LPA also conducted interviews with S1 and R1.

Continue on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

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-20260401142902

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HERITAGE HAVEN	FACILITY NUMBER: 019200506
	VISIT DATE: 04/28/2026

NARRATIVE

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***This is an amended report from visit on 4/28/2026***

Continued from LIC9099.

Allegation: Staff are not providing adequate supervision to the residents in care.

Finding: Unsubstantiated

During record review and interview, LPA discovered that R1 can leave the facility unassisted based on their LIC602 (Physicians report) dated 4/26/2023. S1 stated that R1 is able to leave the facility unassisted. S1 stated that they have previously spoken with the neighbors concerning R1’s behaviors in the community. S1 stated that they explained to the neighbors that R1 has behavioral disorders and the facility provides a space to help improve R1’s behaviors. S1 stated that they have been working with R1’s case manager to help improve R1’s behavior out in the community. R1 stated that there are always staff here to help assist them. R1 stated that they like to go out in the community. During visits on 4/7/2026 and 4/28/2026, LPA observed that there were two staff members working at the facility and there was sufficient staffing.

Based on the investigation, which included interviews of 1 staff and 1 resident, and review of supervision log/sign in sheet, the allegation that Staff are not providing adequate supervision to the residents in care, is unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit Interview conducted with Ferdinand and copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

LIC9099 (FAS) - (06/04)

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