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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426688
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:50:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230502165222
FACILITY NAME:HEARTLAND MANORFACILITY NUMBER:
336426688
ADMINISTRATOR:AHMED QASIMFACILITY TYPE:
740
ADDRESS:178 W. PENDLETON ROADTELEPHONE:
(951) 849-7750
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:22CENSUS: 17DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Amirr Younes, ManagerTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Lack of supervision resulted in resident leaving the facility
INVESTIGATION FINDINGS:
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On 5/09/23, Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Amirr Younes, Manager and discussed the purpose of the visit. The visit consisted of LPA observations, pertinent document review, staff and resident interviews.

Regarding the allegation, lack of supervision resulted in resident leaving the facility, Interviews with staff reveal that resident #1 (R1) walks around the facility without assistance. On 4/29/23, facility staff noticed that R1 was no longer at the facility and called the authorities. R1 was found by authorities and taken to the hospital. Review of R1's physician's report reveal that R1's in not able to leave the facility unassisted due to R1's condition.

Based on evidence obtained during this visit, the preponderance of evidence standard has been met; Therefore, the above allegation are Substantiated. A deficiency is being cited in accordance with California Code of Regulations, Title 22 on the attached LIC 9099D.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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 3
Control Number 56-AS-20230502165222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HEARTLAND MANOR
FACILITY NUMBER: 336426688
VISIT DATE: 05/09/2023
NARRATIVE
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A Plan of Correction was reviewed by Younes. An exit interview was conducted and a copy of this report with appeal rights was provided to the Manager at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230502165222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HEARTLAND MANOR
FACILITY NUMBER: 336426688
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2Additional Personal Rights of Residents... (a) In addition.. care facilities for the elderly shall have... personal rights:(4)To care, supervision, and services that meet their individual needs..this requirement is not met as by:
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Licensee/Administrator read the cited regulation and deliver a self-cerfication statement to the Licensing Division by POC date.
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Staff left R1 unattended and was found by authorities and taken to the hospital.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3