300607488-5-22-2025-22-AS-MSTC-DH766A-20250530203138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300607488
Report Date: 05/22/2025
Date Signed: 05/22/2025 02:04:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
03/12/2025 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250312161858

FACILITY NAME:	HERITAGE POINTE		FACILITY NUMBER:	300607488
ADMINISTRATOR:	JONATHAN PERLES		FACILITY TYPE:	740
ADDRESS:	27356 BELLOGENTE		TELEPHONE:	(949) 364-9685
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	225	CENSUS: 118	DATE:	05/22/2025
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Erin Palposi, Executive Director		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff do not respond to resident’s calls for assistance in a timely manner

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 of the allegations listed above. LPA was greeted and granted entry by front desk staff after stating the purpose of the visit. Executive Director Erin Palposi was present on the premises and assisted with the visit.

The initial complaint investigation visit took place on March 18, 2025. During the visit, LPA requested and obtained the current facility census. LPA additionally requested resident records for five residents of the Sage unit as well as the log for pendant pushes recorded in the facility for the past 30 days. Three resident interviews along with one staff interview were also conducted during the visit.

Additional staff and resident interviews conducted during the annual visit on May 14, 2025. During the follow-up to the investigation, LPA reviewed logged pendant pushes for 30 days ending in March 2025.
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: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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

Control Number 22-AS-20250312161858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HERITAGE POINTE	FACILITY NUMBER: 300607488
	VISIT DATE: 05/22/2025

NARRATIVE

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CONTINUED FROM FORM LIC9099
Regarding the allegation that Staff do not respond to resident’s calls for assistance in a timely manner, the following has been concluded: Based on interviews conducted and records reviewed there are on average 116 pushes per day. When ruling out pushes related to low battery levels in the pendant, there remains 139 pushes for which the response time between call system activation and endorsement of the call by staff exceeded 45 minutes, hence over four daily occurrences of excessive wait for the residents in care.

As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. One type B deficiency is being cited per California Code of Regulations Title 22 and an immediate civil penalty for a repeat violation is being assessed.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
03/12/2025 and conducted by Evaluator Kevin Saborit-Guasch

COMPLAINT CONTROL NUMBER: 22-AS-20250312161858

FACILITY NAME:	HERITAGE POINTE		FACILITY NUMBER:	300607488
ADMINISTRATOR:	JONATHAN PERLES		FACILITY TYPE:	740
ADDRESS:	27356 BELLOGENTE		TELEPHONE:	(949) 364-9685
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	225	CENSUS:	DATE:	05/22/2025
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Erin Palposi, Executive Director		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
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5
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7
8
9

Staff do not ensure that resident is provided with meals in a timely manner

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 of the allegations listed above. LPA was greeted and granted entry by front desk staff after stating the purpose of the visit. Executive Director Erin Palposi was present on the premises and assisted with the visit.

The initial complaint investigation visit took place on March 18, 2025. During the visit, LPA requested and obtained the current facility census. LPA additionally requested resident records for five residents of the Sage unit as well as the log for pendant pushes recorded in the facility for the past 30 days. Three resident interviews along with one staff interview were also conducted during the visit.

Additional staff and resident interviews conducted during the annual visit on May 14, 2025. LPA observed the lunch service being conducted in assisted living and memory care during the present visit.
CONTINUED ON FORM LIC9099-C

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: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20250312161858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HERITAGE POINTE	FACILITY NUMBER: 300607488
	VISIT DATE: 05/22/2025

NARRATIVE

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CONTINUED FROM FORM LIC9099
Regarding the allegation that Staff do not ensure that resident is provided with meals in a timely manner, the following has been concluded: Earlier in 2025, the facility terminated its contract with its former dining vendor for financial reasons. A higher number of staff than anticipated left to remain with the vendor at the time. Facility staff supplemented the missing dining staff with additional shifts from caregiving staff which ensured continuity of service throughout the transition. Based on staff and resident interviews, the transitional period is now almost over and routine service has resumed. Throughout the period however, no incidents involving meals not being served timely were evidenced during interviews conducted.

As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20250312161858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HERITAGE POINTE	FACILITY NUMBER: 300607488
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/20/2025 Section Cited CCR 878464(f)(1)	1 2 3 4 5 6 7	Per CCR 878464(f)(1) on Basic Services: "Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)". This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will utilize the newly hired Wellness Director to keep track and audit pendant pushes regularly, conduct bi-monthly in-service training and identify root causes of excessive wait times. Documentation of the corrections to be provided to LPA before the plan of corrections due date.
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted, multiple instances of excessive response times were recorded.This constitutes a potential risk to the health, safety and personal rights of individuals in care.	8 9 10 11 12 13 14	CIVIL PENALTY FOR REPEAT VIOLATION ASSESSED
	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: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 5