374603778-4-16-2026-08-AS-LTEZ-DWHTS9-20260731145847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603778
Report Date: 04/16/2026
Date Signed: 04/16/2026 11:34:35 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
08/12/2025 and conducted by Evaluator Ramin Hashemi

COMPLAINT CONTROL NUMBER: 08-AS-20250812104236

FACILITY NAME:	HERITAGE HILLS		FACILITY NUMBER:	374603778
ADMINISTRATOR:	MICHAEL MCCOY		FACILITY TYPE:	740
ADDRESS:	2108 EL CAMINO REAL		TELEPHONE:	(760) 206-7930
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92054
CAPACITY:	78	CENSUS: 76	DATE:	04/16/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Executive Director Mike McCoy		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Neglect/Lack of supervision resulting in sexual abuse
Staff did not maintain comfortable temperatures for resident
Staff did not follow resident’s care plan
Staff did not dispose of waste in a proper manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Mike McCoy.

On 08/12/2025 it was alleged that "Neglect/Lack of supervision resulting sexual abuse." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff and records review.

Regarding the allegation, "Neglect/Lack of supervision resulting sexual abuse," it was alleged that a resident sexually abused another resident in a common area due to lack of supervision from care staff.

(Continued on LIC9099C, Page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

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-20250812104236

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HERITAGE HILLS	FACILITY NUMBER: 374603778
	VISIT DATE: 04/16/2026

NARRATIVE

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(Continued from LIC9099C, Page 3)
Records Review demonstrated that facility staff put in work orders for maintenance for R1's hospice equipment on 01/23/25, 01/28/25, 04/10/25, 08/23/25, and 09/05/25. Per the Hospice Inventory item pickup, dated 11/19/2025, R1 had the following equipment for use from 04/10/25 until R1 moved out of the facility on 11/19/25: two fall pads, hospital bed, over bed table, two half rails, mattress, recliner, 2 foot rests, high back wheelchair, and a pommel cushion.

Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

On 08/12/2025 it was alleged that "Staff did not dispose of waste in a proper manner" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, and records review.

Regarding the allegation, "Staff did not dispose of waste in a proper manner", it was alleged that facility staff do not clean the room on a regular basis which resulted in leftover fecal wipes in a resident's room.

Interviews with staff demonstrated that staff are aware of the housekeeping schedules and proper sanitation requirements when providing care for residents. S1 stated, "twice a week that rooms are deep cleaned." With regards to continence care, fecal wipes are disposed in resident waste baskets and after each brief change, the plastic bag goes with caregivers to be delivered to the trash room.

Interviews with Residents conflicted on the cleanliness within the facility. R2 stated that facility staff do not keep the facility clean but clarified that meant staff don't change the linens often enough. R3 stated that the facility was clean and stated their observations that staff are "always sweeping the hallways" or "cleaning up R3's room" when they provide care for them.

Records review of housekeeping records demonstrated that care staff regularly cleaned R1's room during the time period of the complaint.

(Continued on LIC9099C, Page 5)

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20250812104236

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HERITAGE HILLS	FACILITY NUMBER: 374603778
	VISIT DATE: 04/16/2026

NARRATIVE

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(Continued from LIC9099C, Page 4)

LPA observed resident rooms as part of the investigation. Resident rooms did not have trash on the floor, the walls and windows were not dusty or dirty, and the linens appeared clean meaning they did not have noticeable crumbs, dirt, or stains.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Mike McCoy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 08-AS-20250812104236

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HERITAGE HILLS	FACILITY NUMBER: 374603778
	VISIT DATE: 04/16/2026

NARRATIVE

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(Continued from LIC9099C, Page 2)
Interviews with staff demonstrated knowledge of the rights of residents. Staff consistently reported room temperatures were to stay in compliance range around 74 degrees. S1 stated that when staff perform their checks on residents, they check the thermostat and shut/open windows depending on how the room feels and with consent from residents.

Interviews with Residents corroborated staff interviews. In an interview with R3, they stated that the temperature changes in their room but it's not bad. R3 additionally reported that staff supplemented them with an oscillating fan to help regulate the temperature even more.

LPA observations revealed temperatures of rooms of residents were within regulatory compliance.

Based on interviews and direct LPA observations a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

On 08/12/2025 it was alleged that "Staff did not follow resident’s care plan." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, and records review.

Regarding the allegation, "Staff did not follow resident's care plan", it was alleged that facility staff did not ensure that hospice bed rails were maintained on R1's hospice bed.

Interviews with Staff consistently reported that any equipment brought in from hospice as a part of a resident's care plan must be maintained by the hospice provider and cannot be worked on by staff per hospice policy. S1 stated that as a result of an observation from R1's family about their bed rails, S1 placed a work order for R1's half bed rails to receive maintenance and encouraged the family of R1 to call hospice as well. According to staff, R1's family claimed the half bed rail placed against the wall on R1's hospital bed was loose/not attached. S3 stated they inspected the bed rail without adjusting it per hospice policy and that it was attached to the bed. LPA asked staff if R1 had the strength or capacity to push themselves and their bed away from the way to which staff replied that no, R1 was at no risk or strong enough to create that situation and fall between the wall and the bed. Additionally, S1 spoke to R1's family about their request for full bed rails on R1's hospice bed. S1 warned against that and the family's suggestion to put R1's wheelchair against the bed when R1 slept as those accommodations would be considered restraining R1.
(Continued on LIC9099C, Page 4)

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 08-AS-20250812104236

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HERITAGE HILLS	FACILITY NUMBER: 374603778
	VISIT DATE: 04/16/2026

NARRATIVE

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(Continued from LIC9099, Page 1)

Interviews with staff confirmed that Resident 4 (R4) and Resident 5 (R5) have engaged in sexual relations with consent with each other prior to the occurrence witnessed by the reporting party. S1 stated that both R4 and R5 display behaviors such as "inappropriate touching" and "disrobing in public" and that care staff are to redirect residents when they witness these behaviors occurring. S1 stated that the relationship is consensual as both R4 and R5 will seek each other out and that R4 and R5's families are aware of the behaviors. When R4 and R5 express these behaviors, staff follow the care plan (stated as redirection, and offering alternative activities) and report events to the families of the residents.

Records Review was consistent with staff interviews. The physician's report for R4 lists diagnosis as follows: Dementia with behavioral disturbance, cognitive communication deficit, hemiplegia - affecting L nondominant side, and type 2 diabetes mellitus without complications. The service plan report subsection "Behavioral Management Service Plan" states that care staff will provide reorientation within the community and redirection as needed to manage behaviors and that staff will provide close supervision and frequent monitoring, especially in common areas and during interactions with other residents. The care notes for R4 dated from Jan 2025 to Nov 2025 consistently report when R4's condition of exhibiting behaviors as described above and staff's response. The notes include caregivers following the behavioral management service plan when R4 exhibits behaviors. The physician's report for R5 lists diagnosis as follows: Unspecified dementia unspecified severity, psychotic disturbance, mood disturbance, anxiety, and unspecified mood disorder. The service plan report subsection "Behavioral Management Service Plan" states that care staff will redirect resident promptly and respectfully when flirtatious or inappropriate behavior is observed.

Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

On 08/12/2025 it was alleged that "Staff did not maintain comfortable temperatures for resident" The Department’s investigation consisted of unannounced facility visits, interviews with facility staff and residents.

(Continued on LIC9099C, Page 3)

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026

LIC9099 (FAS) - (06/04)

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