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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603778
Report Date: 11/06/2023
Date Signed: 11/06/2023 04:01:40 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
02/15/2023 and conducted by Evaluator Nacole Patterson
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230215104856
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: 70DATE:
11/06/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director Stefanie AnchetaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Staff did not administer medication as prescribed.
Licensee did not ensure resident(s) had access to personal care supplies.
INVESTIGATION FINDINGS:
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8
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10
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13
Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA was welcomed by and discussed the purpose of the visit with Executive Director Stefanie Ancheta.

On 2/15/23, it was alleged that staff did not administer medication as prescribed, and Licensee did not ensure resident(s) had access to personal care supplies. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations.

Regarding the allegation, "Staff did not administer medication as prescribed", it was alleged that a staff member intentionally withheld a resident's pro re nata (PRN) medication when the resident needed it. Staff interview revealed that the resident in question received the PRN medication the day of the incident and that staff monitor residents, assisting with their behaviors when necessary. (Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (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)
Page: 1 of 5
Control Number 08-AS-20230215104856
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)

Records review did not corroborate the allegation, and confirmed that residents exhibiting aggression and/or distress were given PRN medications according to their prescriptions. Resident interviews were not possible due to impaired cognition. LPA observations revealed staff members assisting residents with Activities of Daily Living (ADLs) and redirecting them as necessary.

Regarding the allegation, "Licensee did not ensure resident(s) had access to personal care supplies", it was alleged that the Licensee did not ensure protocols were in place for resident personal care supplies to be maintained. Staff interview did not corroborate the allegation, as staff interviewed exhibited knowledge of the Responsible Party notification process when additional care supplies were needed. Records review revealed that the expectation was for residents and/or their Responsible Parties to provide personal care and hygiene supplies, with an agreed-upon option to pay an additional fee if they preferred the facility to provide these items. LPA observations revealed that the facility has had an emergency stock of personal care supplies, including briefs and incontinence supplies, if a resident ran out before their Responsible Party could bring more.

Based on interviews, observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are 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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (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)
Page: 2 of 5
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
02/15/2023 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20230215104856

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: 70DATE:
11/06/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director Stefanie AnchetaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not treat resident(s) with dignity.
Staff did not meet resident(s) incontinence needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA was welcomed by and discussed the purpose of the visit with Executive Director Stefanie Ancheta.

On 2/15/23 it was alleged that staff did not treat resident(s) with dignity, and staff did not meet resident(s) incontinence needs. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations.

Regarding the allegation, "Staff did not treat resident(s) with dignity", it was alleged that staff pushed residents, spoke to residents in a disrespectful manner, and were instructed to provoke a resident's behaviors so they could be removed from the facility. Staff interviews corroborated this allegation, revealing that a particular staff member (S2) spoke rudely to, and about, residents and staff, and engaged physically with residents in a way that did not maintain their dignity. (Continued on LIC9099-C)
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (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)
Page: 3 of 5
Control Number 08-AS-20230215104856
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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3
4
5
6
7
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10
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15
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(Continued from LIC9099)

Outside source interviews corroborated the allegation, revealing that a staff member exhibited impatience for a resident and spoke about them to others in a way that was disrespectful to the resident. Records review also corroborated this allegation, showing that the staff member in question (S2) was terminated due to inappropriate conduct toward residents and staff. Staff interviews corroborated that staff were instructed to provoke a resident.

Regarding the allegation, "Staff did not meet resident(s) incontinence needs", it was alleged that staff did not assist residents timely with their incontinence needs. Staff interview revealed that staffing levels were low during the timeframe of the complaint, resulting in staff not being able to assist residents immediately when they had incontinence needs. Outside source interview revealed that residents were left in saturated briefs for long periods of time without being assisted and the resident floors had a strong smell of urine. Resident interview corroborated that night staff did not assist residents with incontinence care. During an unannounced facility visit on 2/22/23 LPA directly observed residents walking around with soiled briefs and a strong odor in the facility of incontinence.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. 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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (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)
Page: 4 of 5
Control Number 08-AS-20230215104856
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met, as evidenced by:
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Licensee terminated staff member S2, effective 6/22/23. Licensee agreed to coordinate retraining of all staff on 87468.1 Personal Rights, and to submit the training sign-in sheet(s) to LPA by the POC due date, as proof.
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Based on interviews, Licensee did not accord 1 of 70 residents (R1) dignity in their personal relationships with staff. This posed a potential personal rights risk to persons in care.
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Type B
11/06/2023
Section Cited
CCR
87625(b)(2)(3)
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87625(b)..."Licensee shall be responsible for ensuring (2)...that incontinent residents are checked... when they are known to be incontinent...(3) incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met, evidenced by:
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Licensee agreed to coordinate retraining of all staff on 87625 Managed Incontinence, and to submit the training sign-in sheet(s) to LPA by the POC due date, as proof.
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Based on interviews and observations, Licensee did not: check residents when known to be incontinent, ensure residents' were clean/dry, or ensure the facility remained free of odors of incontinence. This posed a potential health risk to 70 of 70 residents 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: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5