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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801406
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:25:43 PM


Document Has Been Signed on 08/30/2023 04:25 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:HERITAGE RESIDENCEFACILITY NUMBER:
405801406
ADMINISTRATOR:LING H. MANUELFACILITY TYPE:
740
ADDRESS:1724 BADEN AVENUETELEPHONE:
(805) 473-0425
CITY:GROVER BEACHSTATE: CAZIP CODE:
93433
CAPACITY:4CENSUS: 4DATE:
08/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ling Manuel AdministratorTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a case management deficiency visit to the facility above. LPA met with Ling Manuel and explained the purpose of the visit.

LPA De Leon received an incident report from the facility dated 05/17/2023 stating Resident 1 (R1) went out in the backyard to sit in the sun and around 9:00 am R1 wanted to go for a walk leaving out the side gate and not telling staff. The gate was alarmed and 2 staff were present inside the facility, neither heard the gate alarm. Staff continued with staff duties inside the facility. At approximately 10:15 am the Arroyo Grande Police Department (AGPD) contacted the facility Administrator stating they had R1. Administrator went to the AGPD and picked up R1. AGPD stated to the Administrator that R1 was found on the ground by an unknown person which helped R1 by taking R1 back home only R1 could not remember where to go so the unknown person dropped R1 at the Chevron station in Arroyo Grande and AGPD was contacted. Administrator assessed R1 and R1 had no apparent injuries. Administrator asked R1 if they heard the alarm and R1 stated yes but once the gate shut R1 did not hear it any longer. R1 stated R1 was fine. Administrator told R1 that if R1 wants to walk R1 needs to let staff know.

LPA De Leon requested additional information about the incident and a copy of R1’s LIC 602A physicians report, which indicated that R1 was not able to leave the facility unassisted.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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 08/30/2023 04:25 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: HERITAGE RESIDENCE
FACILITY NUMBER: 405801406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2023
Section Cited
CCR
87464(f)(1)

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(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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Administrator agreed to hold an all-staff training for supervision of residents, duties, responsibilities, elopement procedures, and on audible alarm sounds and responses. Provide proof of training with all staff signatures and an up to date LIC 500.
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Based on record review the licensee did not comply with the regulation above, R1 was sitting in the backyard of the facility and was able to leave through the alarmed gates without staff noticing and found by AGPD unsupervised which poses an immediate health and safety risk to resident 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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