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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426688
Report Date: 10/02/2023
Date Signed: 10/02/2023 01:06:49 PM


Document Has Been Signed on 10/02/2023 01:06 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: 21DATE:
10/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Amirr Younes, ManagerTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management deficiencies visit to the facility. LPA met with Amirr Younes, Manager and discussed the purpose of the visit.

During complaint investigation # 56-AS-20230530155755, LPA's record review revealed that staff calls to Banning Police Department and Banning Police Department visits to the facility regarding Resident #2 (R2’s) suspected drug abuse where not reported to Community Care Licensing.

A deficiency was cited during today’s visit and a plan of correction was discussed with Manager Younes. A copy of the is 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: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
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 2


Document Has Been Signed on 10/02/2023 01:06 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: 10/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2023
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency…(1)A written report...within seven days of the occurrence of… (D) Any incident which threatens the welfare, safety or health of any resident...This requirement is not met by:
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Licensee/Administrator shall submit to the licensing agency a self-certified statement of understanding regarding the cited regulation by POC date.
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Staff calls to Banning Police Department and Banning Police department visits to the facility regarding Resident #2 (R2’s) suspected drug abuse where not reported to Community Care Licensing, this poses a potential health, safety, or personnel rights 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: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2