374603778-6-24-2023-08-AS-DPOL-CU6RPG-20230728131155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603778
Report Date: 06/23/2023
Date Signed: 06/24/2023 08:14:04 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/31/2022 and conducted by Evaluator Esther Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220531161724

FACILITY NAME:	HERITAGE HILLS		FACILITY NUMBER:	374603778
ADMINISTRATOR:	LEMASTER, SUZY P		FACILITY TYPE:	740
ADDRESS:	2108 EL CAMINO REAL		TELEPHONE:	(760) 206-7930
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92054
CAPACITY:	74	CENSUS: 71	DATE:	06/23/2023
		UNANNOUNCED	TIME BEGAN:	02:32 PM
MET WITH:	Stefanie Ancheta, Administrator		TIME COMPLETED:	03:13 PM

ALLEGATION(S):

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Staff did not administer medication as prescribed.
Staff did not assist residents with showering.
Staff did not provide incontinence care.
Insufficient staff resulting in falls.
Staff did not follow COVID-19 infection control requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegations. LPA was granted entry to the facility by Stefanie Ancheta, Administrator, after identifying herself and explaining the reason for the visit.

On May 31, 2022, it was alleged that staff did not administer medication as prescribed, staff did not assist residents with showering, staff did not provide incontinence care, there were insufficient number of staff resulting in resident falls, and staff did not follow COVID-19 infection control requirements. The Department’s investigation consisted of review of facility records, outside source records, and interviews of facility staff and outside sources.

Regarding the allegation that staff did not administer medication as prescribed, LPA randomly selected

[Continued on LIC9099-C, Page 1 of 4]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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 4

Control Number 08-AS-20220531161724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/23/2023

NARRATIVE

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with medications. Resident’s needs and service plan showed documented ongoing changes since admission regarding their medications. The documentation showed each resident’s growing level of need for medication management. Facility was able to provide a Medication Administration Record (MAR) for R1, R2, R3, R4, and R5. The MAR documented medication name, time taken, dose, and staff initials. Interviews with R2, R3, and R5’s visitors indicated they did not have concerns with facility not meeting resident’s medication needs. Interviews with R4’s visitors could not be obtained. An outside resident advocate agency also stated there had been no concerns reported to them regarding medication not being administered as prescribed.

It was further alleged that staff did not assist residents with showering and incontinence care. Facility records showed that R1, R2, R3, R4, and R5 needed assistance with bathing. Facility records contained shower and skin monitoring logs for R1, R2, R3, R4, and R5. Records indicated what shift showers were completed on, staff initials, any refusals, if hospice did the shower, and notes regarding skin condition. Interviews with R1, R2, R3, and R5’s visitors indicated they did not have concerns with facility not meeting resident’s bathing needs. Interviews with R4’s visitors could not be obtained. An outside resident advocate agency also stated there had been no concerns reported to them regarding resident’s hygiene or bathing needs not being met.

It was further alleged that facility did not provide incontinence care. Facility maintained incontinence logs, which kept track of the size and time in which residents would have a bowel movement. Facility bowel movement logs for R1, R2, R3, R4, and R5 showed staff members would sign the log during each shift, even if there were no bowel movements. Interview with R1’s visitors indicated that they also saw R1 clean on visits. There were times during their visit where they had to wait for R1 because they were in the shower. Visitors also stated that they never noticed a bad smell from R1 or the facility. Interviews with R2, R3, and R5’s visitors indicated they did not have concerns with facility not meeting resident’s incontinence needs. Interviews with R4’s visitors could not be obtained. An outside resident advocate agency also stated there had been no concerns reported to them regarding resident’s toileting needs not being met.

It was further alleged that there were insufficient staff resulting in residents falling due to lack of supervision. Facility documents show that on June 5, 2022 there were sixty-two (62) residents in assisted living,

[Continued on LIC9099-C, Page 2 of 4]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20220531161724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/23/2023

NARRATIVE

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including memory care. Of those, twenty-seven (27) residents were incontinent and needed staff assistance to toilet. Staff schedule for April and May 2022 showed that facility employed 26 caregivers and medication technicians (med techs). A review of timecards showed that, on a daily basis the facility had fourteen (14) to fifteen (15) caregivers and med techs working. About five (5) to seven (7) working per day shift, and about two (2) working nocturnal shift. Records revealed the facility had self-reported many incidents of residents falling. These incidents are reviewed by the Department and evaluated for violations of Title 22. After review of incidents, the Department did not conduct any follow-up visits for any of the reported falls.

Interviews with R1, R2, R3, and R5’s visitors indicated they did not observe or feel that resident’s needs were not being met. Interviews with R4’s visitors could not be obtained. An outside resident advocate agency also stated that while they felt facility needed more staff during April and May 2022, they did not observe, believe, or receive reports concerning resident’s need’s not being met.

It was further alleged that staff did not follow COVID-19 infection control requirements, specifically that staff did not wear masks. Provider Information Notice (PIN) 22-04-ASC was released February 7, 2022 regarding visitation requirements during the COVID pandemic. Facility kept records of staff and resident vaccination records, as well as records of COVID testing for staff and residents. Facility followed the PINs visitation policy by evidence of facility’s visitor’s records from April 2023 and May 2023. Visitation logs showed each visitor's time in and out, name, room number visiting, visitor's phone number, if they took a COVID test and if it was a rapid test, temperature, if visitor had COVID symptoms, and visitor's signature. A random selection of visitors during this time were interviewed by LPA. All visitors recalled staff wearing masks. Facility training logs also showed that staff were trained on donning and doffing of personal protective equipment, general COVID requirements such as mask wearing, and isolation requirements for residents with COVID. Records indicated that a training was held on January 3, 2022 regarding resident care, the new COVID variant, and “BIBs”. All training logs were signed and dated by staff. Staff interviews indicated that they wore masks and were trained appropriately. An outside resident advocate agency stated that they had not received any complaints regarding the facility not following COVID protocols. Interviews with R2, R3, and R5’s visitors indicated they did not have concerns with facility not following COVID protocols. Interviews with R4’s visitors could not be obtained.

[Continued on LIC9099-C, Page 3 of 4]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 08-AS-20220531161724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/23/2023

NARRATIVE

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Based on the evidence obtained during the complaint investigation, all allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator; a copy of this report and Licensee's Rights (LIC9058) were provided.

[Continued from LIC9099-C, Page 4 of 4]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4