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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 03:22:29 PM


Document Has Been Signed on 01/08/2024 03:22 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Jaclyn Nava, AdministratorTIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Jaclyn Nava, Administrator, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (64) and a current census of (50) residents in care. The facility has a hospice waiver for (10) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility has sufficient indoor and outdoor shaded areas for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathrooms inspected at random, were operating in safe and sanitary conditions. The hot water temperature in residents' bathrooms measured between 105 and 108 degrees F. Resident’s bedrooms inspected at random, have sufficient lighting and furniture in good repair. Facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen and personal care items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, evacuation plan, resident monthly activities and resident's personal rights.
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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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
VISIT DATE: 01/08/2024
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Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerators and freezers are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas.

Care & Supervision: Facility has 24-hour, 7 days a week care staff.

Record Review: The facility conducted a disaster drill on 9/21/2023. Resident files reviewed were observed to be complete. Review of staff files reveals, the facility did not maintain a health screening with tuberculosis results for staff #1 (S1).

Medical Related Services: All medication is centrally stored and kept secure in a locked room.

Based on LPA observations and record review, a deficiency is being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where reports LIC809/LIC809D/LIC9102 were discussed with the Administrator and copies of the reports with Appeal Rights were provided 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
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/08/2024 03:22 PM - 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: 01/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Records
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA file review, the licensee did not comply with the section cited above by: the facility did not maintain a health screening with tuberculosis results for staff #1 (S1), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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The licensee shall submit to the Licensing Agency documentation of staff's tuberculosis results by POC due date.
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: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5