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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607488
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:22:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HERITAGE POINTEFACILITY NUMBER:
300607488
ADMINISTRATOR:MIKE SILVERMANFACILITY TYPE:
740
ADDRESS:27356 BELLOGENTETELEPHONE:
(949) 364-9685
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:225CENSUS: 151DATE:
12/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Mike Silvermen, Executive DirectorTIME COMPLETED:
02:36 PM
NARRATIVE
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On today's date, Licensing Program Analyst (LPA) LPA Quiroz while concluding findings for Complaint Control #22-AS-20210614115537, LPA Quiroz met with Executive Director Mike Silvermen. On or about 12:00pm, while LPA Quiroz along with Executive Director Mike Silvermen toured Memory Care, LPA Quiroz observed four staff and nine residents in dining-room area. Two of four staff were assisting resident's with feeding, and two of four staff were assisting other residents in dining-room during lunch.
On or about 12:07, while LPA Quiroz was touring Room 6A where one of ten residents from memory care reside, LPA Quiroz pulled alarm chord in bathroom with Executive Director Mike Silvermen present. No response, after 9 minutes, Executive Director addressed the chord and reset it.
LPA Quiroz interviewed Director of Health Care, Executive Director and four of four staff working in Memory Care who indicated not having beepers on their possession and indicated having to be alerted by any other staff outside of memory care regarding alarm system.
Today's call light log record reviewed revealed the LPA triggered alarm at 12:07pm, and it was reset at 12:16pm, after Executive Director who was present at the time with LPA Quiroz reset it.
Based on LPA's observations, interviews which were conducted and record review, deficiency will be cited during today's visit under California Code of Regulation (CCR) Personal Rights: 87468(a).

This report was reviewed with Executive Director Mike Silvermen and Tracii Brown Director of Health Care, and a copy of this report, LIC 809 D and Appeal Rights were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HERITAGE POINTE
FACILITY NUMBER: 300607488
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2021
Section Cited

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Personal Rights- (a) Residents in residential care facilities for the elderly shall have personal rights...those listed in Sections 87468.1,Personal Rights... and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. CONTINUED BELOW
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This requirement was not met as evidenced by:Resident's call light alarm in Room 6A was not nswered in a timely manner. Based on LPAobservation and interviews which were conducted, resident call light alarms are not answered in a timelymanner. This poses a potential health, CONTINUED ...
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CONTINUED...safety and personal rights risk to residents 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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