374603778-9-23-2022-08-AS-IESA-CKR7FJ-20221031213736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603778
Report Date: 09/23/2022
Date Signed: 09/23/2022 03:43:22 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/13/2022 and conducted by Evaluator Daniela Huerta

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220913093619

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: 72	DATE:	09/23/2022
		UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	Stefanie Ancheta, Executive Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulted in resident eloping from facility.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Daniela Huerta and Interim Assistant Program Administrator (IAPA) Icela Estrada conducted an unannounced visit to commence an investigation for the above allegation. LPA and IAPA identified themselves and met with Executive Director Stefanie Ancheta to discuss the purpose of the visit and elements of the complaint.

It was alleged that lack of supervision resulted in a resident eloping from the facility. The Department’s investigation consisted of a review of facility records, review of resident medical records, outside source records, and interviews of facility staff and outside sources.

Evidence indicates that Resident 1 (R1) [licensee was provided an LIC 811 Confidential Names List that identifies the resident] moved into the facility on September 6, 2022.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniela Huerta	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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 3

Control Number 08-AS-20220913093619

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 09/23/2022

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
26
27
28
29
30
31
32

A Physician’s Report dated July 13, 2022, indicates R1 has “wandering behavior” and is “not able to leave facility unassisted”.

The Preplacement Appraisal LIC 603 dated August 30, 2022, also indicates R1 has wandering behaviors and documents that R1 needs “safety checks”. Interview with Executive Director revealed that it is standard practice to conduct a head count (safety check) on residents every two hours.

Records and interviews revealed that on September 6, 2022, R1 was last seen between 6:30 PM and 7:00 PM by R1’s main caregiver (S1). At 6:30 PM, S1 went on a 30-minute break and notified her colleagues via radio that she was going on break. During the interview, Executive Director explained that while S1 was on break the other two caregivers working on the 2nd floor were responsible for the care and supervision of the residents assigned to S1. At 9:30 PM, the facility received a call from a local hospital stating R1 was found at approximately 8:30 PM in the community by a good Samaritan, who then called 9-1-1 to have R1 transported to the emergency room as it appeared R1 had a fall. A review of facility cameras revealed R1 did not exit via the main doors which are equipped with delayed egress. It is suspected that R1 exited via the “back servery doors” that are not equipped with delayed egress or an alarm system. Interviews revealed R1 was not observed by staff for approximately 2.5 to 3 hours and learned of the resident missing when they received notification from the local hospital at 9:30 PM. R1 was admitted to the local hospital at approximately 9:10 PM and was diagnosed with “contusion, forehead; fall; hip pain” and was discharged back to the facility on September 7, 2022, at 1:27 AM.

The Department has investigated the complaint alleging lack of supervision resulted in a resident eloping from the facility. Based on evidence obtained, facility staff was not aware of R1’s whereabouts for up to 3 hours, despite R1’s documented wandering behavior and need for safety checks. Accordingly, the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D.

An exit interview was conducted, a plan of correction was jointly developed, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Stefanie Ancheta, Executive Director. Signature on this form confirms receipt of the documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniela Huerta	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20220913093619

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/24/2022 Section Cited CCR 87464(f)(1)(c)	1 2 3 4 5 6 7	87464 Basic Services (f)(1)(c) Basic Services. Care and supervision as defined in section 87101(c)(3) and Health and Safety Code section 1569.2(c). “Care and Supervision” means the facility assumes responsibility for…on going assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director Stefanie Ancheta was pro active in providing In- Service training to staff on 9/7/2022 regarding the servery doors to remain closed at all times. Place service order to adjust the hydraulic spring device on the servery door by the POC due date of 9/24/2022.
	8 9 10 11 12 13 14	Based on record review and interviews, the licensee did not provide basic services for 1 out of 72 residents, by not providing the required supervision which poses an immediate health and safety risk to residents 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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniela Huerta	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3