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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426688
Report Date: 06/01/2023
Date Signed: 06/01/2023 12:02:47 PM


Document Has Been Signed on 06/01/2023 12:02 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 16DATE:
06/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Grace Reyes - House ManagerTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management visit in conjunction with complaint #56-20230530155755. LPA Malcore met with Grace Reyes, House Manager and discussed the purpose of the visit

During today's visit, LPA discovered one (1) staff member present without the proper background check clearance. Staff #1 (S1) interview reveals that S1 has been working for the facility since 05/27/23. S1 stated not having fingerprints clearance conducted. Interview with Reyes reveal that S1 has been working part-time for the facility since 05/27/23 but is not associated with the facility. LPA asked Reyes if S1 has received and does not know if S1 has received background clearance.

Therefore, based on the observations made during today’s visit, the following deficiency was cited per Title 22, of the California Code of Regulations. See LIC 809D. An exit interview was conducted and a copy of this report with appeal rights was provided to the Grace Reyes, House 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: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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 06/01/2023 12:02 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
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: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2023
Section Cited
CCR
87411(g)(1)

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87411 Personnel Requirements...(g)prior to employment or initial presence in the facility, all employees and volunteers...shall:(1) Obtain a California clearance...as required by law..this requirement is not met as evidenced by:
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Staff (S1) immediately left facility. Licensee/Administrator will submit a written statement of understanding of the regulation cited by POC due date.
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The Licensee did not obtain a criminal record clearance for Staff #1 (S1) prior to S1 beginning employment or initial presence in the facility. This poses an immediate health and safety risk to residents in care.
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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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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