<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360900455
Report Date: 11/17/2023
Date Signed: 11/17/2023 11:04:08 AM


Document Has Been Signed on 11/17/2023 11:04 AM - 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:
11/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Jaclyn Nava, AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to conduct a Health and Safety check to the facility. LPA met with Administrator Jaclyn Nava, and discussed the purpose of the visit.

LPA Malcore observed no immediate health and safety concerns; However, Administrator Nava did not have an Administrator Certification. Administrator Nava provided LPA verification of Administrator course completion. Administrator Nava stated she will submit a Administrator Certification Application (LIC9214) today, 11/17/23.

Based on the observations made during today’s visit, a deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report was discussed, and a copies of reports (LIC809/LIC809-D) with Appeal Rights were 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: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 11/17/2023 11:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2023
Section Cited
CCR
87406(a)

1
2
3
4
5
6
7
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. This requirement is not met by:
1
2
3
4
5
6
7
Licensee/Administrator shall provide verification of a certified and associated Administrator by POC due date.
8
9
10
11
12
13
14
Licensee did not comply with the regulation cite by Administrator Nava did not have an Administrator Certification, which poses an potential health, safety, and personal rights risk to persons 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 ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2