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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200506
Report Date: 07/01/2026
Date Signed: 07/01/2026 04:49:49 PM

Substantiated


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
03/19/2026 and conducted by Evaluator Yasamin Brown
COMPLAINT CONTROL NUMBER: 15-AS-20260319151737
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: 21DATE:
07/01/2026
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Ancheta Rillera, Caregiver TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not ensure the facility is free of hazards
Staff do not ensure the facility is free of mold
Staff do not ensure the facility is in good repair
Staff do not provide adequate lighting for residents
INVESTIGATION FINDINGS:
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On 7/1/2026 at 2:15 pm, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a continued complaint investigation and deliver findings for the allegations above. LPA met with Ancheta Rillera, Caregiver and explained the purpose of the visit.

During the investigation, LPA reviewed the LIC500 (Personnel Report) and LIC9020 (Resident Roster). LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. LPA interviewed three (3) staff and four (4) residents.

Allegation: Staff do not ensure the facility is free of hazards
Finding: Substantiated

Continued on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
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 5
Control Number 15-AS-20260319151737
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: 07/01/2026
NARRATIVE
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Continued from LIC9099.

During Investigation, on 5/27/2026 and 7/1/2026, LPA toured the facility inside and out, including bedrooms, bathroom, living room, kitchen, dining area, garage and outside area. LPA observed drill bits and screwdriver bits in the upstairs restroom unlocked. LPA also observed Ez Patch Spackling Compound, Paint and Joint Compound unlocked in the downstairs restroom. LPA observed WD Spray, Clorox bleach and detergent unlocked in the garage.

Allegation: Staff do not ensure the facility is free of mold


Finding: Substantiated

During Investigation, on 3/27/2026, 5/27/2026 and 7/1/2026, LPA toured the facilities resident bathrooms and LPA observed mold in the resident showers, bathtubs, and around the bottom of the toilets. Interview with staff revealed that there is mold in the residents restrooms in the showers, bathtubs and around the toilets. Staff stated that they clean everyday but it is difficult to remove the mold.

Allegation: Staff do not ensure the facility is in good repair


Finding: Substantiated

During Investigation, on 3/27/2026, 5/27/2026 and 7/1/2026, LPA toured the facility inside and out, including bedrooms, bathroom, living room, kitchen, dining area, garage and outside area. LPA observed that the facility is currently under a construction plan to repair some items in the facility. LPA reviewed the construction contract and timeline and observed that there is no concrete deadline of completion. LPA observed that the construction contract they received from the facility is dated 9/25/2024. LPA observed that some of the items on the contract have not been completed. LPA observed that the light bulbs upstairs are damaged and not operable.

Continue to LIC9099-C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20260319151737
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2026
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times...

This requirement is not met as evidenced by:


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By POC date, Licensee agrees to complete a detailed construction timeline with a completetion date and change the non operable lightbulbs and replace them with new lightbulbs and submit a copy of the construction timeline and self-certification letter stating that the light bulbs were changed to CCLD.
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Based on observation and interview, the licensee did not comply with the section cited above in that the construction contract does not have a concrete timeline of completion and the light bulbs upstairs are non operable
which poses a potential health and safety risk to persons in care.
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Type B
07/08/2026
Section Cited
CCR
87303(d)
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87303 Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility

This requirement is not met as evidenced by:

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By POC date, Licensee agrees to remove the single light strip and replace the light fixtures and submit photo proof that this was completed to CCLD.
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Based on observation and interview, the licensee did not comply with the section cited above in that the facility is using a single light strip in the resident hallway and multiple light fixtures are non operable which poses a potential health and safety risk to persons in 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20260319151737
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: 07/01/2026
NARRATIVE
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Continued from LIC9099-C.

Allegation: Staff do not provide adequate lighting for residents
Finding: Substantiated

During Investigation, on 3/27/2026, 5/27/2026 and 7/1/2026, LPA toured the facilities hallways and observed that the facility is using a single light strip in the resident hallway which is not adequate lighting for residents. LPA observed that multiple light fixtures are not operable in the upstairs hallways for the residents. Interview with residents and staff revealed that there are multiple light fixtures that are not operable in the facility. LPA observed the light bulb in the upstairs bathroom was not operable.


Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Administrator verbally authorized Ancheta to sign today's report.

Exit interview was conducted with Ancheta, Appeal Rights and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20260319151737
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2026
Section Cited
CCR
87309(a)
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87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions.. tools, sharp objects.. could pose a danger to residents..
This requirement is not met as evidenced by:
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By POC date, Licensee agrees to remove and put them in a locked cabinet and submit a self certification letter stating that this was completed to CCLD.
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Based on observation and interview, the licensee did not comply with the section cited above drill bits, screwdriver bits, Ez Patch Spackling Compound, Paint and Joint Compound, WD Spray, Clorox bleach and detergent unlocked which poses an immediate health and safety risk to persons in care.
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Type B
07/08/2026
Section Cited
CCR
87303(1)
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87303 Maintenance and Operation
(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
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By POC date, Licensee agrees to have shower, bathtub and toilets deeply cleaned and the mold removed and submit photo proof that this was completed to CCLD.
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Based on observation and interview, the licensee did not comply with the section cited above in that the residents bathtub, showers and toilet had mold which poses a potential health and safety risk to persons in 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5