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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607488
Report Date: 03/28/2024
Date Signed: 03/28/2024 05:11:40 PM


Document Has Been Signed on 03/28/2024 05:11 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HERITAGE POINTEFACILITY NUMBER:
300607488
ADMINISTRATOR:JONATHAN PERLESFACILITY TYPE:
740
ADDRESS:27356 BELLOGENTETELEPHONE:
(949) 364-9685
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:225CENSUS: 123DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marjorie Silberman, Interim Executive DirectorTIME COMPLETED:
05:00 PM
NARRATIVE
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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 conducting the required annual inspection. LPA was greeted and granted entry by front desk staff after introducing himself and stating the purpose of the visit. Interim Executive Director Marjorie Silberman was notified and assisted with the visit.

LPA reviewed the facility's resident census, staff roster, Emergency and Disaster Plan, Infection Control Plan, staff schedules. A sample of ten staff records and ten resident records were reviewed during the visit.

The facility is a two-story building divided in three sections (Assisted Living, Sage Living and Memory Care) around a central courtyard with a secure swimming pool. LPA accompanied by administrator conducted a tour of the interior and exterior of the physical plant. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms were operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 115 degrees Fahrenheit in memory care and 109 degrees Fahrenheit in Sage living resident bathrooms. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to residents in care. LPA reviewed the physician orders and contents of one of the facility's medication cart. Fire extinguishers were mounted and charged. For the exterior portion, facility has several patio furniture sets with umbrellas for shade and the grounds and routes of egress were free of tripping hazards.

One type B deficiency was cited per Title 22 Division 6 of the California Code of Regulations and three Technical Assistance Advisory Notes were provided. An exit interview was conducted and a copy of this report along with appeal rights was left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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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Document Has Been Signed on 03/28/2024 05:11 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
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: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a review of a sample of resident records, the licensee did not comply with the section cited above as two physician reports reviewed in a total of 10 had been conducted more than a year prior to the visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2024
Plan of Correction
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Licensee will obtain updated medical assessments for the two residents in question and provide LPA with proof of update by the plan of corrections due date of April 28, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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