360900455-11-10-2021-18-AS-EMAN-C9AUC4-20211201142718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 360900455
Report Date: 11/10/2021
Date Signed: 11/10/2021 03:02:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/08/2020 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200508122120

FACILITY NAME:	HERITAGE GARDENS		FACILITY NUMBER:	360900455
ADMINISTRATOR:	LEAK, LISA		FACILITY TYPE:	740
ADDRESS:	25271 BARTON RD		TELEPHONE:	(909) 796-0219
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	64	CENSUS: 41	DATE:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	01:29 PM
MET WITH:	Lisa Leak		TIME COMPLETED:	03:18 PM

ALLEGATION(S):

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Staff are not providing resident with diapers and liners

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to initiate an investigation into the above complaint allegations and deliver the findings. LPA met with Administrator Lisa Leak.

The first allegation, Staff are not providing resident with diapers and liners. Administrator stated Resident 1’s (R1’s) diapers and liners are provided by Innovage. Administrator stated R1 was provided with adult diapers with pull tabs while awaiting Innovage order to arrive. R1 stated she does not usually run out of diapers and liners, but she did once and the facility gave her large plastic adult diapers with sticky tabs until her order came in.
Based on interviews and although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted where this report was discussed and provided to the administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/08/2020 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200508122120

FACILITY NAME:	HERITAGE GARDENS		FACILITY NUMBER:	360900455
ADMINISTRATOR:	LEAK, LISA		FACILITY TYPE:	740
ADDRESS:	25271 BARTON RD		TELEPHONE:	(909) 796-0219
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	64	CENSUS: 41	DATE:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	01:29 PM
MET WITH:	Lisa Leak		TIME COMPLETED:	03:18 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not following Dr. orders

INVESTIGATION FINDINGS:

1
2
3
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5
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13

Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to initiate an investigation into the above complaint allegations and deliver findings. LPA met with Administrator Lisa Leak.

The investigation consisted of interviews and record review. The first allegation, Staff are not following Dr. orders. Administrator stated the doctors order was followed except on 5/10/2020 as there was no skilled professional staff to apply the treatment. Resident 1 (R1) stated staff did not apply the treatment as ordered. R1 stated the treatment was missed on one day.
Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, 9099D, LIC 811 and appeal rights were discussed and provided to the administrator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20200508122120

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HERITAGE GARDENS	FACILITY NUMBER: 360900455
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/17/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered	1 2 3 4 5 6 7	The Licensee will read the regulation in it's entirety and submit a statement of understanding to CCLD by the POC due date of 11/17/2021.
	8 9 10 11 12 13 14	medications as needed. This requirement is not met as evidenced by: Facility staff did not give topical treatment medication as prescribed for Resident 1. This poses a potential health, safety, and personal rights risk to person's in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC9099 (FAS) - (06/04)

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