<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603778
Report Date: 12/30/2024
Date Signed: 12/30/2024 01:10:00 PM

Document Has Been Signed on 12/30/2024 01:10 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HERITAGE HILLSFACILITY NUMBER:
374603778
ADMINISTRATOR/
DIRECTOR:		STEFANIE ANCHETAFACILITY TYPE:
740
ADDRESS:2108 EL CAMINO REALTELEPHONE:
(760) 206-7930
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY: 78CENSUS: 69DATE:
12/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Executive Director Mike McCoyTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
 Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Assistant Resident Service Director Starsha Borja. Executive Director Mike McCoy and Resident Service Director Evalyn Valaile arrived during the visit.

Today's visit was in response to a self-reported incident of Resident 1 (R1) found chewing on two pencil sharpeners during arts and craft resulting in staff finding two single razor blades in R1's mouth. [See LIC811 Confidential Names List.]

During today’s visit, LPA performed a brief facility tour and welfare check on R1. LPA also collected copies of and reviewed R1's care and medical records. According to their latest LIC602 Physician’s Report, R1 was diagnosed with Alzheimer's disease and Dementia. Due to their baseline memory loss, R1 was not able to serve as a reliable historian/interviewee for this case.

Staff interviews unanimously showed: Resident's are not to be allowed access to pencil sharpeners due to safety concerns. Sharpeners were to be used by staff to sharpen resident's pencils.

Staff interviews further show: R1 has a history of putting inedible objects into their mouth and there is no consensus on how R1 obtained the sharpeners. Direct cares staff were supervising R1's floor (the first floor), activity staff were on the second floor conducting a different activity.

One (1) deficiency was cited per California Health and Safety Code. An exit interview was conducted with Executive Director Mike McCoy and Resident Service Director Evalyn Valaile, to whom a copy of this report, the LIC811 Confidential Names List, the LIC809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/30/2024 01:10 PM - It Cannot Be Edited


Created By: Hannah Rodgers On 12/30/2024 at 12:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HERITAGE HILLS
FACILITY NUMBER: 374603778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2025
Section Cited
HSC
1569.312(e)

1
2
3
4
5
6
7
1569.312 Basic services requirements: "(e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being." This requirement was not met as evidence by:
1
2
3
4
5
6
7
Licensee agrees to conduct a training for their current direct care staff and activities staff on the topic of Monitoring Activities & Supervision. Licensee agrees to send training agenda and sign in sheet to CCL by POC date of 01/29/2024.
8
9
10
11
12
13
14
Based on interview, the licensee did not comply with the section cited above in one (1) out of sixety-nine (69) residents which posed a potential health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Tellez
LICENSING EVALUATOR NAME:Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2