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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360900455
Report Date: 06/07/2022
Date Signed: 06/07/2022 11:26:50 AM

Substantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220606123614
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: 49DATE:
06/07/2022
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Lisa Leak-Administrator TIME COMPLETED:
11:36 AM
ALLEGATION(S):
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Staff are not providing resident with diapers.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegation.

LPA Gardner met with Administrator Lisa Leak and explained the reason for the visit. At the time of visit there were seven (7) staff and forty-nine (49) residents present.

LPA Gardner interviewed two (2) staff members (S1, S2) and interviewed two (2) residents (R1, R2). LPA Gardner found through interviews and record review that R1 is supplied pull-up diapers by the company Innovage. The facility has been calling Innovage to obtain diapers since May 16, 2022. Innovage continually told the facility that, “they are going to put in an order.”
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
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-20220606123614
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
, CA 92507
FACILITY NAME: HERITAGE GARDENS
FACILITY NUMBER: 360900455
VISIT DATE: 06/07/2022
NARRATIVE
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As of today, the facility has not received diapers for R1 from Innovage. The Administrator admitted that the facility supplied R1 with the wrong sized pull-up diapers from May 16, 2022 to June 7, 2022. R1 wears a size 2XL pull-up diaper and the facility provided R1 with size XL pull-up diapers. The Administrator admitted that she was aware that the pull-up diapers were too small and that they were hurting R1. LPA Gardner inquired if the Administrator had contacted a different company to find an alternative solution until Innovage could supply the correct size pull-ups. The Administrator admitted she did not contact another company and did not try to find a solution to get R1 the correct size pull-up diapers.

During today’s visit, the Administrator called Innovage and the company delivered eight (8) packs of size 2XL pull-up diapers.

Based on interviews conducted and record review the allegation is deemed SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Based on interviews conducted and record review made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Administrator Lisa Leak, along with a copy of the appeal rights.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20220606123614
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
, CA 92507

FACILITY NAME: HERITAGE GARDENS
FACILITY NUMBER: 360900455
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2022
Section Cited
CCR
87625(a)(1)(D)
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(a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances:(1) The condition can be managed with any of the following:(D) The use of incontinent care products.
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The licensee has agreed to read regulation 87625 entirely and send self-certify letter to LPA that it was read and understood. The licensee has agreed to create an alternative plan for when residents run out of their correct diaper size to ensure residents are wearing the correct size diaper to manage incontinent care and ensure residents are not in pain from diapers provided.
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Based on interviews and record review, the licensee did not comply with the section cited above knowingly providing pull-up diapers that did not fit R1, and that were causing R1 pain. The diapers provided were not able to manage incontinent care correctly which poses an immediate health, safety, or personal rights risk to persons in care.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3