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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413073
Report Date: 11/09/2022
Date Signed: 11/09/2022 09:35:10 AM

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
02/03/2021 and conducted by Evaluator Natalie Ibarra
COMPLAINT CONTROL NUMBER: 18-AS-20210203164702
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: 51DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Erika MontoyyaTIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
2
3
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5
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8
9
Facility staff failed to dispense resident's medication as prescribed
Facility staff abandoned resident
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Natalie Ibarra conducted an unannounced visit to the facility to deliver findings for the above allegations. LPA met with Assistant Administrator Erika Montoya and explained the purpose of today’s visit. Investigation consisted of interviews with pertinent parties and records review.

The first allegation indicates facility staff failed to dispense resident's medication as prescribed. Interviews with Staff #1 (S1) and Staff #2 (S2) stated that medication was being dispensed to Resident #1 (R1) as prescribed. LPA reviewed R1’s MARs and observe medication was being administered as per doctor orders.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Natalie Ibarra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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 2
Control Number 18-AS-20210203164702
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 COURT ASSISTED LIVING
FACILITY NUMBER: 366413073
VISIT DATE: 11/09/2022
NARRATIVE
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The second allegation indicates facility staff abandoned resident. Interviews with S1 and S2 stated that R1 was not abandoned. S1 stated that the facility was not able to meet R1’s needs and wanted R1 to be evaluated at a psych ward before readmitting. S1 provided hospital social worker with the facility that was willing to take R1 and had an opening. LPAs reviewed R1’s hospital progress notes and social worker notes. Progress note on 2/2/21 states patient has no new symptoms and is awaiting in-patient psych facility placement. Social service notes from 1/29/21 states social worker got a call stating MD wants patient to be placed at a psych facility.

Based on the information obtained, the allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of this report was discussed and provided to Assitant Administrator Erika Montoya.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Natalie Ibarra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2