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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300607488
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:29:25 PM


Document Has Been Signed on 08/02/2022 04:29 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, 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: 134DATE:
08/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Mike Silverman, CEO
Tracii Brown, Resident Care Director
Tiffany Kennebrew, LVN		TIME COMPLETED:
04:45 PM
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On 08/02/2022 at 2:15pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a case management visit following up on a mandatory incident report transmitted to the Department on 08/01/2022. LPA was greeted and granted entry by Mike Silverman, CEO after being explained the purpose of the visit.

Incident report received alleges instances of verbal and physical abuse by a member of staff (S1) towards resident R1 on the evening of 07/30/2022. A report of the incident was made to the Department, the Long Term Care Ombudsman as well as the Orange County Sheriff Department.

LPA conducted multiple interviews with Mike Silverman, as well as staff members S2 and S3 as well as resident R1 and a family member present (R2). The caregiver against whom the allegations have been made has been suspended pending the result of the investigation and is not present within the facility at the time of the visit. Staff member is correctly associated and cleared in Guardian.

Based on the observations made during today’s case management visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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