374603778-11-6-2023-08-AS-LTEZ-CXTTUQ-20231122140244

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603778
Report Date: 11/06/2023
Date Signed: 11/06/2023 04:12:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
03/29/2023 and conducted by Evaluator Nacole Patterson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20230329120448

FACILITY NAME:	HERITAGE HILLS		FACILITY NUMBER:	374603778
ADMINISTRATOR:	STEFANIE ANCHETA		FACILITY TYPE:	740
ADDRESS:	2108 EL CAMINO REAL		TELEPHONE:	(760) 206-7930
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92054
CAPACITY:	74	CENSUS: 70	DATE:	11/06/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Executive Director Stefanie Ancheta		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Lack of supervision resulted in resident sustaining injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Executive Director Stefanie Ancheta.

On 3/29/23 it was alleged that lack of supervision resulted in a resident sustaining an injury when a resident (R1) had an episode of physical aggression against another resident (R2). The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, and outside sources. Staff interview revealed that residents R1 and R2 were directly observed by staff (S1) at 4:00pm and found to be at baseline with no visible injuries; residents were checked again at 4:30pm and R2 was found with minor injuries, noted as bruises. Records review revealed that on the day of the event, R2 had been visited by an outside agency for care and an outside individual for visitation; neither party noted injury for R2 prior to staff observation.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230329120448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HERITAGE HILLS	FACILITY NUMBER: 374603778
	VISIT DATE: 11/06/2023

NARRATIVE

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(Continued from LIC9099)

Staff interview and records review revealed that the incident was investigated internally, confirming that R1 experienced an acute symptom of physical aggression from a preexisting medical condition. Staff interviews and records review showed that staff documented the behavioral incident, assisted both residents with medical care, and notified resident physicians and the Responsible Parties timely. Outside sources interviewed stated that the facility had supervision concerns during the timeframe of the complaint allegation; however, no interviews or records corroborated that there was a lack of supervision at the time of the incident.

Based on interviews, observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Stefanie Ancheta , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

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