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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200506
Report Date: 01/14/2025
Date Signed: 01/14/2025 02:36:30 PM

Document Has Been Signed on 01/14/2025 02:36 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/
DIRECTOR:		FERDINAND GUTIERREZFACILITY TYPE:
740
ADDRESS:389 JUANA AVENUETELEPHONE:
(510) 357-1300
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 27CENSUS: 22DATE:
01/14/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Ferdinand Gutierrez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 01/14/2025 at 1:50 PM Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management visit regarding information obtained that a resident was missing from an Unusual Incident Report (UIR) received on 1/6/2025. LPA met with Administrator, Ferdinand Gutierrez and explained the purpose of the visit.

LPA K. Nguyen interviewed S1 that confirmed that R1 was missing on 1/03/2025 and returned back to the facility on 01/07/2025. S1 stated that R1 leaves almost every day since R1 were admitted which was 08/5/2024. However, on this particular day, R1 did not return. S1 stated that R1 went to see R1 husband in Oakland without informing any staff. R1 had a court order that R1 husband are not to be near R1, and R1 husband are not supposed to be at the facility as well. S1 stated that R1 is trying to find ways to see R1 husband. We cannot stop R1 from leaving the facility. LPA interviewed R1 and R1 stated that R1 went to see R1 husband because R1 haven’t seen R1 husband for 3 months. R1 stay at R1 husband house, and R1 husband brought R1 back to the facility. R1's Physician's Report indicates that R1 are able to leave the facility unassisted.

LPA reviewed R1 files and confirmed R1 physician report that R1 is able to leave the facility unassisted.

No deficiency issue on today date.

Exit interview conducted and a copy of this report is provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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