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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603778
Report Date: 07/10/2023
Date Signed: 07/10/2023 03:05:57 PM


Document Has Been Signed on 07/10/2023 03:05 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:HERITAGE HILLSFACILITY NUMBER:
374603778
ADMINISTRATOR:STEFANIE ANCHETAFACILITY TYPE:
740
ADDRESS:2108 EL CAMINO REALTELEPHONE:
(760) 206-7930
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:74CENSUS: 71DATE:
07/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Executive Director Stefanie AnchetaTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Stefanie Ancheta.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 07/05/2023). According to the LIC624: on 07/02/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] R1 was found by staff shortly after and was brought back inside the facility unharmed.

During today’s visit, LPA performed a brief facility tour and welfare check, verifying that R1 was indeed unharmed/uninjured. LPA also reviewed pertinent care and administrative records and interviewed relevant staff.

According to their latest LIC602 Physician’s Report (dated 04/26/2023), R1 was diagnosed with both “Major Neurocognitive Disorder” and “Dementia,” and their doctor determined that they were not able to safely leave the facility unassisted. Due to their baseline memory loss, R1 was not able to participate as a reliable historian/interviewee about the incident.

Per LPA observation, the entire facility is a dedicated memory care unit, and the building utilizes delayed-egress exit doors, each of which currently unlock after 15 seconds. One such delayed-egress door leads from the facility’s second floor to the “South Stairwell,” and down to the facility’s parking garage, which then has a driveway leading back to the front of the facility, which faces the street “El Camino Real.”

[CONTINUED ON LIC 809-C

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HERITAGE HILLS
FACILITY NUMBER: 374603778
VISIT DATE: 07/10/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

Per staff interviews: During the afternoon of 07/02/2023, Staff #1 (S1) heard the activation of the alarm on the second floor's "South Stairwell" delayed-egress door, and went to investigate. (Time and date-stamped electronic alarm logs showed the alarm was manually reset after 36 seconds.) S1 arrived at the now-unlocked door and checked the stairwell and parking garage. Upon seeing no resident in either location, S1 went back inside and called “all clear” on the radio to their co-workers. Licensee’s staff did not perform a resident head count and were initially unaware that R1 was missing from the facility. Approximately five (5) minutes after the alarm was reset, Staff #2 (S2) incidentally encountered R1 outside the building trying to get back inside.

Based on the particulars of the incident, a preponderance of evidence exits to show that licensee’s staff did not have the training necessary to respond to delayed-egress doors in a way that preserved resident safety.

Based on records review, and confirmed by management interview: Licensee did not possess a written Absentee Notification Plan on R1 at the time of the incident, as was required.

Deficiencies were cited per California Health and Safety Code and California Code of Regulations, Title 22 (refer to the attached LIC809-D page). Plans of Correction were jointly developed with the Licensee.

LPA also issued one Technical Violation regarding reporting requirements (refer to the LIC9102-TV page).

An exit interview was conducted with Ancheta, to whom a copy of this report, the LIC809-D, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/10/2023 03:05 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: HERITAGE HILLS
FACILITY NUMBER: 374603778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2023
Section Cited
CCR
87411(a)

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87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be…competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by:
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Licensee agreed to codify in writing new procedures/expectations regarding how staff should respond after discovering that a delayed-egress door has alarmed and unlocked. The actions will include but are not limited to: 1) Finding the source/person who opened the door, and 2) Performing a head count of the residents to ensure all are accounted for. Licensee agreed to train its staff on these procedures, and E-mail the training sign-in sheet to LPA by the POC due date.
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Based on interviews, within the context of effective searching following a delayed-egress door alarm, the licensee did not ensure facility personnel were competent to provide the services necessary to meet the needs of 1 of 71 residents (R1), which posed a potential safety risk to persons in care.
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Type B
08/09/2023
Section Cited
HSC1569.317

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1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan…”
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During today’s visit, Licensee wrote an Absentee Notification Plan and provided a copy of it to LPA. Licensee agreed to print and add this document as an addendum the written record of care for each of its current residents. Licensee agreed to train all its current staff on this document, and to E-mail the training sign-in sheet to LPA by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff did not develop an absentee notification plan for 71 of 71 residents (R1 through R71), which posed a potential safety 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
LIC809 (FAS) - (06/04)
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