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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413073
Report Date: 07/13/2023
Date Signed: 07/13/2023 10:44:35 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
07/05/2023 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230705120759
FACILITY NAME:HERITAGE COURT ASSISTED LIVINGFACILITY NUMBER:
366413073
ADMINISTRATOR:SCHLOTTMAN, JACOBFACILITY TYPE:
740
ADDRESS:275 GARNET WAY BTELEPHONE:
(909) 204-5000
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:88CENSUS: 50DATE:
07/13/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Assistant Administrator Erika MontoyaTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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Staff do not ensure facility is kept free of pests for residents in care.
INVESTIGATION FINDINGS:
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On 07/13/2023 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to deliver findings for the allegation listed above. LPA Brown was greeted and granted entry by a staff at the reception area and Assistant Administrator Erika Montoya was contacted and LPA Brown explained the purpose of the visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

Through the information gathered during the investigation, it was confirmed by observation, documents review and interviews that there are still roaches in the facility after cleaning and spraying for them was conducted. Although the facility is taking action for the roaches, as Assistant Administrator Montoya indicated, it appears that there is not sufficient treatment being done by the facility’s contracted exterminator to aggressively rid the roaches. Also, Assistant Administrator Montoya reported that the facility will have a sufficient follow up to their contracted exterminators to control the roaches in the building. Interviews with staff also indicated knowledge of roaches at the facility. *** Cont. in LIC9099C ***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
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-20230705120759
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 COURT ASSISTED LIVING
FACILITY NUMBER: 366413073
VISIT DATE: 07/13/2023
NARRATIVE
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LPA Brown toured the facility with Assistant Administrator Montoya last 07/12/2023 at around 10:15 AM and LPA Brown observed bugs traps placed at residents’ rooms and at Assistant Administrators’ Montoya’s office as well. Also, during the visit, Assistant Administrator Montoya reported that they are aware of the roaches at the facility, and they already drafted an agreement with their contracted exterminator but still pending approval from their management. LPA Brown requested for the facility’s exterminator monthly services invoices record and LPA Brown observed monthly services conducted but per Assistant Administrator Montoya’s statement to LPA Brown that the contracted exterminator is spraying the outside of the facility and whatever the reported issue was. LPA Brown recommended to Assistant Administrator Montoya that in addition to spraying the outside of the facility, the contracted exterminator must sprayed/serviced all rooms, not just selected resident rooms. Assistant Administrator Montoya reported that they have a plan with the contracted exterminator to address the issue that is for signature by their management already which is to sprayed/service not selected room, but all rooms must be sprayed.

Based on observation and interviews, the allegation of Staff do not ensure facility is kept free of pests for residents in care is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.



An exit interview was conducted and a copy of this report, LIC9099, LIC9099D and appeal rights was discussed and provided to Assistant Administrator Erika Montoya.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230705120759
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 COURT ASSISTED LIVING
FACILITY NUMBER: 366413073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety... This requirement was not met as evidenced by:
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Licensee stated to call exterminator within 24 hours to have exterminator services performed on the inside and outside of the facility and a plan of procedure shall be submitted to LPA Brown no later than COB 07/14/2023 regarding the roaches observed at the facility.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not aggressively addressing the roaches’ issue at the facility which poses immediate health, safety and personal rights risks to resident in care.
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LPA Brown will also receive all receipts of services for the roach’s service/treatment once performed no more than 24 hours after services performed.

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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3