197608268-3-2-2023-28-AS-LHIS-CQBJXG-20230327072615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608268
Report Date: 03/02/2023
Date Signed: 03/02/2023 11:12:39 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/15/2022 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20221115090235

FACILITY NAME:	HERITAGE SENIOR HOME CARE		FACILITY NUMBER:	197608268
ADMINISTRATOR:	NINO NAVARRO		FACILITY TYPE:	740
ADDRESS:	820 GLENLEA STREET		TELEPHONE:	(626) 272-1540
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS: 5	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Administrator Michelle Navarro		TIME COMPLETED:	11:27 AM

ALLEGATION(S):

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Staff are not providing residents a safe and healthful environment.
Facility does not have adequate staffing to meet resident's needs.
Facility has mold.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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On 03/02/2023 at 9:05 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with administrator Michelle Navarro and explained the reason for the visit. The initial complaint visit was conducted on 11/21/2022.

During the initial visit LPA toured the facility with the Administrator, obtained resident/ staff roster, staff schedule, text correspondence between Administrator and Family member of resident# R5. LPA also received a copy of claim acknowledgement and correspondence with nationwide dated 10/11/2022 and took photos of facility flooring. LPA interviewed administrator, staff#1 (S1) and Staff#2(S2). Residents # R1 through R3 is nonverbal. LPA attempted to interview resident# R4, but due to communication limitations, LPA was not able to continue with the interview.

Report Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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 3

Control Number 28-AS-20221115090235

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE SENIOR HOME CARE	FACILITY NUMBER: 197608268
	VISIT DATE: 03/02/2023

NARRATIVE

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During today’s visit LPA reviewed resident files and obtained R1-R4 physician’s report, and resident roster. LPA interviewed facility Insurance broker and obtained a copy of claim acknowledgement from the insurance broker. LPA and the Administrator toured the facility to ensure no signs of molding. Prior to the visit LPA received a report from All state with results of facility inspection.

The investigation reveals the following: Regarding “Staff are not providing residents a safe and healthful environment” it is alleged that the facility is producing contaminated air ventilation. During the visit LPA toured the facility and observed no indication of air pollution. Staff interview revealed that they do not have signs and symptoms of illness/sickness caused by air pollution. LPA reviewed resident files and did not find any resident with pneumonia. The Administrator confirmed that a former resident moved out abruptly and had pneumonia. The Administrator further stated the resident had a history of pneumonia and confirmed that all current residents was never hospitalized for pneumonia.

The investigation reveals the following: Regarding “Facility does not have adequate staffing to meet resident's needs”. It is alleged the facility has insufficient staffing. Upon arrival LPA observed two (2) caregivers in the facility during visit and on the initial visit dated 11/21/2022. Staff interviews revealed that the facility always have 2 staff working and sometimes the administrator will also be present. Staff further stated that they do not feel the facility is short staffed. The Interview with the administrator, revealed that 2 staff and 2 administrators are schedule Monday through Fridays, and 1 caregiver is scheduled to the night shift. LPA reviewed staff schedules and observed Monday through Fridays the facility has 2 staff scheduled to work during the day and 1 staff scheduled for the night shift.

Report Continued on 9099c

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221115090235

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE SENIOR HOME CARE	FACILITY NUMBER: 197608268
	VISIT DATE: 03/02/2023

NARRATIVE

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The investigation reveals the following: Regarding “Facility has mold”. It is alleged the facility has mold throughout the facility. During the visit LPA toured the facility and observed no signs of molding or white oozing substance. LPA did observe white substance on lining on one floorboard that was hard. interviews with the Administrator revealed that the facility has never had mold. Interviews with staff revealed that they have never seen mold while working at the facility. LPA also consulted with another LPA who was at the facility for another investigation on 12/12/2022, and confirmed mold was not observed during their visit.

The investigation reveals the following: Regarding “Facility is in disrepair”. It is alleged the facility floors are buckled. During tour of the facility LPA did observe buckled floors with possible signs of water damage. During the interview with the administrator, it was revealed the floor buckled in October and the facility is in contact with their insurance company to repair the floors. The administrator presented LPA with an email proving that an insurance claim was filed on 6/26/2022 and correspondence between the facility and the insurance company. On 11/22/2022 The facility sent LPA a report of findings from the insurance company citing the damaged floors was due to the house being built without the perimeter gap between the floors. The facility proceeded with a private contractor and repaired the floors prior to LPA’s next visit. LPA received photos from the administrator on 12/20/2022 showing the repaired flooring. During today’s visit LPA confirmed the flooring was repaired by the facility. The Administrator stated the claim was not submitted on 6/26/2022 as the document stated and provided the insurance broker information. Interview with the insurance broker confirmed the date was a mistake and the claim was filed 10/10/2022.

Based on LPA's observation, interviews, and file review the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Administrator Michelle Navarro and a copy of this record provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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