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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426688
Report Date: 01/03/2024
Date Signed: 01/03/2024 02:42:16 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
12/29/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231229155530
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: 14DATE:
01/03/2024
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Amirr Younes, ManagerTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff were not aware of resident's whereabouts.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with House Manager Amirr Younes and explained the purpose of the visit. The investigation consisted of interview and review of records.


First allegation, Staff were not aware of resident's whereabouts. During interview with S#1 and S#2 both staff informed LPA that R#1 leaves the facility unsupervised. In addition, S#1 informed LPA that R#1 normally returns back to the facility. S#1 reported to LPA that there were two incidents reported to CCL (11/13/2024 and 12/29/2023), where R#1 left the facility unsupervised, and R#1 was brought back to the facility by Banning Police Department. During review of records LPA observed that R#1 is not able to leave the facility unassisted. Based on the evidence gathered during the investigation, the above allegation is Substantiated.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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-20231229155530
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: 01/03/2024
NARRATIVE
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Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Additional Personal Rights of Residents 87468.2 (4), a from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights. to House Manager Amirr Younes at the end of the visit.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20231229155530
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: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
87468.2(4)
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Additional Personal Rights of Residents (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This Requirement is not met as evidenced by:
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Licensee/Administrator will read over Additional Personal Rights of Residents regulation and provide staff training regarding each resident individual needs and services and provide the signed document by all staff to LPA Guerrero on POC date 1/31/2024.
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Based on interviews, and record review, facility staff permitted an ineligible resident (R#1), to leave the facility unassisted, and was later brought back to the facility by local law enforcement.
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3