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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360900455
Report Date: 01/08/2024
Date Signed: 01/08/2024 03:28:02 PM


Document Has Been Signed on 01/08/2024 03:28 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:HERITAGE GARDENSFACILITY NUMBER:
360900455
ADMINISTRATOR:LEAK, LISAFACILITY TYPE:
740
ADDRESS:25271 BARTON RDTELEPHONE:
(909) 796-0219
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:64CENSUS: 50DATE:
01/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Jaclyn Nava, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management visit to follow-up on an incident reported to Community Care Licensing Division Regional office on 1/05/2024 by the facility. LPA met with Jaclyn Nava, Administrator and discussed the purpose of the visit.

During today's, LPA obtained pertinent documentation and conducted interviews with resident #1(R1) and resident #2 (R2). The facility also conducted interviews with staff, residents involved and reported the incident that occurred on 1/03/2024 to the local Ombudsman and Sheriff department.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and a copy of this report was provided to the Administrator 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: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
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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