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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603778
Report Date: 04/25/2023
Date Signed: 04/25/2023 03:09:49 PM


Document Has Been Signed on 04/25/2023 03:09 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: 68DATE:
04/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Executive Director Stefanie AnchetaTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted a complaint investigation visit where an unrelated deficiency was discovered. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Stefanie Ancheta.

During the unrelated complaint investigation, LPA Ruiz conducted interviews and records review, which revealed that an incident report was not submitted to the Department regarding an incident that occurred in January 2023, where Resident 1 (R1) had fallen resulting in no injuries and 911 was contacted to assess R1's condition. Review of the facility's incident reports submitted to the Department did not show an incident report for the fall in January 2023. Interviews with the Executive Director confirmed that any incidents, including falls, that do not result in an injury are not reported to the Department. Per California Code of Regulations Title 22, the following deficiency is cited on the attached LIC809-D page.

An exit interview was conducted with Executive Director Stefanie Ancheta, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
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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Document Has Been Signed on 04/25/2023 03:09 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: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/05/2023
Section Cited
CCR
87211(a)(a)

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87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement has not been met as evidenced by:
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Executive Director stated they will review regulation 87211 and submit a letter to the Department stating understanding of reporting requirements and will submit incident reports for all incidents, regardless of injury by POC due date.
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Based on interviews and records review, the Licensee did not submit an incident report to the Department regarding R1's fall. This poses an potential safety risk to 68 of 68 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: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
LIC809 (FAS) - (06/04)
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