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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603778
Report Date: 08/16/2023
Date Signed: 08/16/2023 12:15:19 PM


Document Has Been Signed on 08/16/2023 12:15 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
SO. CAL AC/SC, 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:
08/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Yesenia Reyes, Resident Services DirectorTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Yesenia Reyes, Resident Services Director, to discuss the purpose of the visit.

Today's visit is in response to the self reported Incident regarding Resident 1 (R1 - see LIC811 Confidential Names List), who was assessed to have an unstageable wound.

LPA collected facility records and conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date.

An exit interview was conducted with Yesenia Reyes, Resident Services Director, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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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