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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602976
Report Date: 10/28/2022
Date Signed: 10/28/2022 12:15:36 PM


Document Has Been Signed on 10/28/2022 12:15 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:HERITAGE RESIDENTIAL HOME CAREFACILITY NUMBER:
198602976
ADMINISTRATOR:NAVARRO, NINO SUNGLAOFACILITY TYPE:
740
ADDRESS:2322 SIENA CTTELEPHONE:
(626) 272-1540
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
10/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nino and Michelle Navarro- AdministratorsTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required Annual Inspection, using the Infection Control Evaluation Tool. LPA Maldonado met with caregiver Rizza Rivera and explained the purpose of the visit. Administrators Nino and Michelle Navarro arrived shortly after to assist with the visit. The physical plant was toured, resident files and medications records were reviewed, staff files were reviewed and food supply was inspected.

The facility is a home, located in a residential area. It is licensed to serve 6 residents of age range 60 and over. It is approved for 6 non-ambulatory residents, of which 1 may be bedridden and has an approved hospice waiver for 4. LPA and caregiver Rizza toured the facility which included the following: 5 resident rooms, 1 staff room, 3 bathrooms, living room, television room, dining room, kitchen, sitting area, office room, laundry room, attached garage and backyard. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction and hazards. The water temperature was tested in 3 bathrooms and measured between 111.9*F -113.7*F degrees which is within the required 105*F - 120*F degrees. Resident bedrooms have the required furniture and bed linens, all in good condition. Bedrooms also have sufficient closet and storage space. There is a closet in the hallway with extra clean linens. Smoke detectors and carbon monoxide detectors were observed throughout the facility. They were tested and observed to be operating. Auditory devices were seen on all exit doors which are required for dementia residents and were operating a the time of visit. LPA observed 2 fire extinguishers throughout the facility which were fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Cleaning supplies and toxins are locked and are inaccessible to residents. First Aid kits were inspected and were fully stocked with current manuals.


(Report Continued on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 RESIDENTIAL HOME CARE
FACILITY NUMBER: 198602976
VISIT DATE: 10/28/2022
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COVID-19 signage was observed and posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. All hand wash stations were observed to be fully stocked with hand soap, paper towels, and hand sanitizer. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.

4 staff files were reviewed for Criminal Background Clearance and required training certification. 6 out of 6 resident files were reviewed for updated emergency contact information and current Physician's Reports for residents with Dementia. Medication Administration Records (MARs) and centrally stored medications were reviewed. Medications are centrally stored in a locked closet in the living room. During the medication review, LPA observed that (1) medication for Resident# 1 (R1) was being administered with the wrong dose as is currently prescribed.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, Article 8, deficiencies were observed and are cited on the LIC9099-D page.

An exit interview was conducted with the Administrators, and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/28/2022 12:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 RESIDENTIAL HOME CARE
FACILITY NUMBER: 198602976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2022
Section Cited

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87465 Incidental Medical and Dental Care
(c) ...facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:(2)...the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
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Based on observation, records review, and interview, the licensee failed to administer R1's medication as prescribed by physician. Melatonin of 3mg was prescribed, but R1 was being administered Melatonin of 5mg, which poses an immediate Health, Safety, or Personal Rights 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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
LIC809 (FAS) - (06/04)
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