336426688-2-2-2024-56-AS-NBRN-D2TQ6J-20240226105336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336426688
Report Date: 02/02/2024
Date Signed: 02/02/2024 10:34:11 AM

Unsubstantiated

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
01/31/2024 and conducted by Evaluator Amber Coleman

COMPLAINT CONTROL NUMBER: 56-AS-20240131092049

FACILITY NAME:	HEARTLAND MANOR		FACILITY NUMBER:	336426688
ADMINISTRATOR:	AHMED QASIM		FACILITY TYPE:	740
ADDRESS:	178 W. PENDLETON ROAD		TELEPHONE:	(951) 849-7750
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY:	22	CENSUS: 16	DATE:	02/02/2024
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Grace Reyes, House Manager		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Staff did not ensure resident's physician's report was complete prior to admissions.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Heartland Manor, Residential Care Facility for the Elderly unannounced to initiate a complaint investigation into the allegation listed above. LPA introduced self and stated purpose of the visit. LPA was greeted and granted entry by House Manager, Grace Reyes, (S1) S1 contacted Administrator, Ahmed Qasim, (S2) to notify of LPA visit and purpose of the visit. LPA spoke with S2 over the phone and House Manager.

During the course of this investigation, LPA collected pertinent documentation, interviewed staff and completed a walk through of the facility. LPA made no observations of any imminent health or safety concerns during the walk through. It is alleged that staff did not ensure resident's Physician's Report was complete prior to admission. The staff interviewed revealed that R1 was admitted to the facility two weeks prior. R1 belongs to a medical healthcare program, who is responsible for completing the Physician's Report.

Please see LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20240131092049

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: 02/02/2024

NARRATIVE

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Administrator reported that the facility and Medical Healthcare Program are both in conflict to get the document completed properly. A review of the record revealed that the document is completed, dated a signed with an attached addendum. The document is missing information which has been communicated to the Medical Healthcare Program. At this time, the facility is awaiting a response from the Program's Management Team to obtain the corrected, completed document.

According to Title 22, Division 6 Chapter 1, 80069(a) Client Medical Assessment, "Except for licensees of ARFs , prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client..." R1 was admitted to the facility January 17th, 2024, the facility has thirty days to obtain the completed Physician's Report for R1.

Based of staff interviews and record reviews, we have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with a facility representative. A copy of this report was reviewed, discussed then provided to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

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