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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360900455
Report Date: 09/20/2024
Date Signed: 09/20/2024 02:44:05 PM

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
03/15/2024 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240315115831
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: 30DATE:
09/20/2024
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jessica RamosTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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5
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9
Facility staff did not meet resident's incontinence care needs
INVESTIGATION FINDINGS:
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5
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9
10
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12
13
Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conclude the complaint investigation and deliver findings on the above allegation. LPA met with Administrator Jessica Ramos who was informed of today’s visit.
Regarding the allegation, staff did not meet the resident's incontinence care needs, interviews with five (5) staff and six (6) residents reveals not enough evidence to corroborate the allegation.
Based on LPA record review, staff and resident interviews, the allegation above is Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
An exit interview was conducted where this report was discussed and a copy of this report was provided to Administrator Ramos at the conclusion of the visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
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 4
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
03/15/2024 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240315115831

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: 30DATE:
09/20/2024
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jessica RamosTIME COMPLETED:
02:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not safeguard resident's belongings
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conclude the investigation and deliver findings on the above allegation. LPA met with Administrator Jessica Ramos who was informed of today’s visit.

Regarding the allegation, facility staff did not safeguard resident's belongings, Interviews with staff, residents, and record review corroborate the above allegtion, resident #1 (R1) had been previously discharged from the facility and readmitted back on 2/02/24. Upon R1's returned it was discovered that the facility no longer had possession of R1's dresser/mirror and night stand. Review of facility's theft and loss records reveals, R1's dresser/mirror and night stand were documented as missing. On 3/14/24, the facility reimbursed R1 for the missing furniture.

Based on LPA record review, staff and resident interviews, the allegation is Substantiated. A determination that the complaint is substantiated means that the allegation(s) is/are valid because the preponderance of the evidence standard has been met.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
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 4
Control Number 56-AS-20240315115831
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: HERITAGE GARDENS
FACILITY NUMBER: 360900455
VISIT DATE: 09/20/2024
NARRATIVE
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An exit interview was conducted where reports (LIC9099/LIC9099C/LI9099-D) were discussed with Administrator Ramos. A copy of the reports were provided with appeal rights 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: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20240315115831
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: HERITAGE GARDENS
FACILITY NUMBER: 360900455
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2024
Section Cited
CCR
87217(b)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables(b)Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met at evidenced by:
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The facility reimbursed resident for missing furniture on 3/14/24. No futher action is required.
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The licensee did not comply with the section cited above by not safeguarding R1's personal property as R1's dresser/mirror and night stand were documented at missing.
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7
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7
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7
1
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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 ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4