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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336407790
Report Date: 12/28/2023
Date Signed: 12/28/2023 11:27:00 AM


Document Has Been Signed on 12/28/2023 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:HERITAGE RESIDENTIAL CAREFACILITY NUMBER:
336407790
ADMINISTRATOR:MARIA ARACELI UNDANFACILITY TYPE:
740
ADDRESS:20975 MARIPOSA ROADTELEPHONE:
(951) 245-0892
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:6CENSUS: 5DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Alexander Angulo- CaregiverTIME COMPLETED:
11:37 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver Alexander Angulo and was granted entry to the facility.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents, one (1) resident may be bedridden. The current census is five (5) residents. LPA was accompanied by Caregiver to conduct a general overall inspection, which included, but was not limited to, the following:

The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA measured and observed the water temperature in the bathrooms to be at 129.3 degrees F. The facility will be issued a deficiency for not having the water temperature within the correct temperature range. LPA observed sufficient furniture and lighting throughout the facility. The facility has residents with a condition that requires auditory devices on the facility exit doors. The facility does not have working auditory devices on the exit doors in the living room, laundry room, staff room #1, bedroom #2, and bedroom #3. The facility will be issued a deficiency for not having auditory alarms on the facility exit doors. LPA found holes in the ceiling and the wall covered with trash bags and tape in the staff room #1. LPA found holes in the ceiling in the laundry room covered with trash bags and tape. LPA was informed by the Administrator that the holes were made in the wall and ceiling to add fire sprinklers, but the Administrator has since decided not to complete the addition of the fire sprinklers.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 12/28/2023 11:27 AM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: HERITAGE RESIDENTIAL CARE
FACILITY NUMBER: 336407790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced by interview and document review, the licensee did not comply with the section cited above evidenced by not conducting a quarterly drill which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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The licensee has agreed to read HSC 1569.695 entirely and send LPA a statement of understanding that the HSC was read and understood. The licensee has agreed to conduct a drill and send LPA proof by the POC date. The license has agreed that moving forward a quarterly drill will be conducted. POC is due by 1/4/2024.
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced by interview and document review, the licensee did not comply with the section cited above evidenced by not completing a needs and services plan, LIC625, for residents R1, R2, R4, and R5 which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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The licensee has agreed to read HSC 1569.695 entirely and send LPA a statement of understanding that the HSC was read and understood. The licensee has agreed to complete a needs and services plan, LIC625, for the residents and send proof to LPA by the POC date. POC is due by 1/4/2024.
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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 12/28/2023 11:27 AM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: HERITAGE RESIDENTIAL CARE
FACILITY NUMBER: 336407790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87212(c)
Emergency Disaster Plan
(c) Emergency exiting plans and telephone numbers shall be posted.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced by interview and document review, the licensee did not comply with the section cited above evidenced by posting a Disaster Plan, LIC610E, which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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The licensee has agreed to read regulation 87212 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to complete a Disaster plan, LIC610E, post the plan in the facility, and send proof to LPA by the POC date. POC is due by 1/4/2024.
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced by interview and observation, the licensee did not comply with the section cited above evidenced by the bathroom sink water being measured at 129.3 degrees F which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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The licensee has agreed to read regulation 87303 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to adjust the water temperature to the correct temperature range by the POC date. POC is due by 1/4/2024.
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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 12/28/2023 11:27 AM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: HERITAGE RESIDENTIAL CARE
FACILITY NUMBER: 336407790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced by interview and observation, the licensee did not comply with the section cited above evidenced by having holes in the ceiling in the laundry room covered with trash bags and tape and having holes in the wall and ceiling in the staff room covered with trash bags and tape which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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The licensee has agreed to read regulation 87303 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to repair the wall and ceilings in the laundry room and the staff room by the POC date. POC is due by 1/11/2024.
Type B
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met as evidenced based on interview and observation, the licensee did not comply with the section cited above evidenced by not having an auditory devices on the facility exits in the living room, laundry room, staff room #1, bedroom #2, and bedroom #3 which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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The licensee has agreed to read regulation 87705 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to install auditory devices on all facility exits. POC is due by 1/4/2024.
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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HERITAGE RESIDENTIAL CARE
FACILITY NUMBER: 336407790
VISIT DATE: 12/28/2023
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 The facility will be issued a deficiency for having holes in the walls and the ceiling. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, and the CCL complaint poster were posted in a common area. The facility does not have disaster plan, LIC610E posted, and the facility has not conducted a disaster drill since 1/10/2021. LPA was informed by the Administrator that they knew they did not conduct a recent disaster drill or have a disaster plan posted in the facility. The facility will be issued deficiencies for not posting a disaster plan and for not conducting a disaster drill quarterly. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident and staff files. Medications are kept inside the hallway cabinet inaccessible to residents. Non-perishable and perishable food supply is sufficient for the residents in care. Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

LPA reviewed six (6) residents files for admission agreements, updated physician reports, and needs and services plans. LPA found that Resident’s R1, R2, R4, and R5 do not have needs and services plans, LIC625. The facility will be issued a deficiency for not having needs and service plans for the residents.

LPA reviewed three (3) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

Based on the observations made during today’s visit, six (6) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D forms, and LIC811 were discussed and provided to Caregiver Alexander Angulo, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5