300607488-6-2-2023-22-AS-SSAS-CT6TFX-20230626144214

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300607488
Report Date: 06/02/2023
Date Signed: 06/02/2023 04:18:27 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230323104336

FACILITY NAME:	HERITAGE POINTE		FACILITY NUMBER:	300607488
ADMINISTRATOR:	MIKE SILVERMAN		FACILITY TYPE:	740
ADDRESS:	27356 BELLOGENTE		TELEPHONE:	(949) 364-9685
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	225	CENSUS: 129	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Georgianna Mendez, Chief Executive Officer		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Toxic chemicals are accessible to residents

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation into the four allegations listed above. LPA was greeted and granted entry by Administrator Georgianna Mendez after explaining the purpose of the visit.

An initial complaint investigation visit was conducted at the facility on March 28, 2023. LPA accompanied by administrator conducted a tour of the Memory Care unit. Records of training for three Med Tech staff assigned to the unit were reviewed at that time.

During today's visit, LPA conducted additional observation of the Memory Care unit along with staff interviews with Memory Care unit Med Tech and staff in charge of scheduling shifts in the facility.

CONTINUED ON FORM LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230323104336

FACILITY NAME:	HERITAGE POINTE		FACILITY NUMBER:	300607488
ADMINISTRATOR:	MIKE SILVERMAN		FACILITY TYPE:	740
ADDRESS:	27356 BELLOGENTE		TELEPHONE:	(949) 364-9685
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	225	CENSUS: 129	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Georgianna Mendez, Chief Executive Officer		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

1
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8
9

Staff is not qualified to administer medication

Staff is not qualified to give doctor's orders

Staff unable to meet resident needs

INVESTIGATION FINDINGS:

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13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 22-AS-20230323104336

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HERITAGE POINTE	FACILITY NUMBER: 300607488
	VISIT DATE: 06/02/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099-A

Regarding the allegations that Staff is not qualified to administer medication and that Staff is not qualified to give doctor's orders, the following has been concluded:

The training records for a random sample of Med Tech staff assigned to the Memory Care unit were requested, obtained and reviewed during the initial complaint investigation visit on March 28, 2023. Additional interviews with staff involved in assisting with the self-administration of medications conducted on June 2, 2023 were also held. A majority of the evidence gathered confirms that Med Tech staff at the facility have received the training required by Title 22 regulations in order to participate in medication dispensation according to the physician's orders on file with the facility. The two allegations are therefore deemed to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur.

Regarding the allegation that Staff unable to meet resident needs, the following has been concluded:

Interviews were conducted with Med Tech staff present in the Memory Care unit on the day of the follow-up visit as well as with the facility staff member in charge of supervising all care and Med Tech staffing. Based on the evidence gathered, staffing levels are confirmed to be adequate to the number of residents in care in the unit. Staffing levels reviewed on both the provisional and effective documents requested and obtained confirm the present of a minimum of two care staff and one Med Tech on each of the two daytime shifts (up to a minimum of three care staff and one Med Tech when Memory Care census reaches 12 residents). Staff interviews confirm the facility's ability to collectively address residents' needs as they occur. As a result, the allegation is deemed to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20230323104336

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HERITAGE POINTE	FACILITY NUMBER: 300607488
	VISIT DATE: 06/02/2023

NARRATIVE

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CONTINUED FROM FORM LIC9099

Regarding the allegation that Toxic chemicals are accessible to residents, the following has been concluded:
During the tour of the physical plant conducted by LPA on March 28, 2023, prescribed and/or over-the-counter medication or treatments were found to have been left accessible in two of the eight bathrooms of the Memory Care unit, which is targeted towards residents with a confirmed dementia diagnosis. A type A deficiency to California Code of Regulations Section 87705(f)(2) regarding the Care of Persons with Dementia is therefore being cited at this time. Based on the follow-up observation conducted today, the deficiency is confirmed to have been corrected and cleared at this time.

As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met.

An exit interview was conducted and a copy of this report along with appeal rights was provided and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20230323104336

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HERITAGE POINTE	FACILITY NUMBER: 300607488
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/03/2023 Section Cited CCR 87705(f)(2)	1 2 3 4 5 6 7	The California Code of Regulations Section 87705 states that: "(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, (...) and toxic substances (...)." This requirement is not met as evidenced by:	1 2 3 4 5 6 7	During the initial visit on March 28, 2023, staff confirmed that the medication in question should have been secured in the medication cart and proceeded to relocate it. Upon follow-up visit on June 2, 2023, the correction was confirmed to have been (...)
	8 9 10 11 12 13 14	Based on observations and interviews conducted during the initial inspection, substances falling under this regulation were found in two Memory Care bathrooms. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.	8 9 10 11 12 13 14	implemented and was still in place. Therefore the plan of corrections is considered to be effective and the deficiency was cleared during the visit.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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