405801406-10-2-2023-29-AS-KBUY-CX5KBU-20231031074606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801406
Report Date: 10/02/2023
Date Signed: 10/02/2023 01:48:40 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/29/2023 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20230929150014

FACILITY NAME:	HERITAGE RESIDENCE		FACILITY NUMBER:	405801406
ADMINISTRATOR:	LING H. MANUEL		FACILITY TYPE:	740
ADDRESS:	1724 BADEN AVENUE		TELEPHONE:	(805) 473-0425
CITY:	GROVER BEACH	STATE: CA	ZIP CODE:	93433
CAPACITY:	4	CENSUS: 4	DATE:	10/02/2023
		ANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Ling Manuel, Administrator		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Staff does not provide adequate supervision resulting in residents wandering away from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted 10-day Complaint visit to the facility above. LPA met with Administrator Ling Manuel and explained the purpose of the visit.

LPA requested Resident 1 (R1's) preplacement Appraisal, LIC.602A Physicians report, Appraisal Needs and Services Plan, staff roster, residents roster and incident report. LPA conducted interview with Administrator, Staff 1 (S1) and R1.

On the allegation: Staff does not provide adequate supervision resulting in residents wandering away from facility. LPA interviewed S1 which revealed that R1 was exit seeking on 09/28/2023 and when staff 2 (S2) went into the restroom and S1 went to help another resident, R1 opened and went out the front door, the alarm went off and S1 went to the front door to see what was going on when S1 observed R1 across the street with 2 neighbors, S1 went back inside and grabbed S1's cell phone then proceeded outside across the street meeting up with R1 and 2 neighbors and they all walked with each other bringing R1 back to the facility. Continued 9099

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230929150014

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/02/2023

NARRATIVE

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Administrator stated she was not here on 09/28/2023, R1 is a new resident was admitted on 09/04/2023, on 09/26/2023 R1 was exit seeking and went out the front door followed by Administrator R1 did not AWOL Administrator had eyes on R1 at all times, S1 did call Administrator on 09/28/2023 and reported R1 was exit seeking and went out across the street with neighbors and had to be redirected back to the facility. R1's interview revealed R1 wants to leave the facility and S1 was trying to redirect R1 inside the facility but once S1 was with another resident R1 left out the front door and crossed the street when 2 neighbors approached R1, then S1 came outside and they all walked R1 back to the facility, R1 was OK, R1 did not have any injuries and does not want anyone to get in trouble. R1 was always able to leave R1's home and is not understanding why R1 can not leave the facility, it was explained to R1 that R1 can leave the facility but needs to let the staff know so they can assist R1 on a walk when R1 wants to go outside. Administrator contacted R1's family and doctor regarding the exit seeking and medications have been adjusted to help with wandering. Administrator stated the facility has not had any another incidents of resident AWOL over the past month only exit sekking and wandering with staff supervision and redirection. Based on the evidence this allegation is Substantiated at this time.

Administrator has placed a door stop alarm at the front door for further safety measures. Administrator is observing R1 with medication adjustments and taking R1 for walks to help with the wandering behaviors.
Administrator will be looking into locked exiting doors and secured perimeter fence gates with the local fire authority to see if the facility would qualify to update the fire clearance with added safety measures. Administrator will also talk with R1's family regarding a wonder guard or apple air tag bracelet for added safety measures for R1.

Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230929150014

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/03/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	(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:	1 2 3 4 5 6 7	The 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 to CCL.
	8 9 10 11 12 13 14	Based on interviews the licensee did not comply with the regulation above, R1 was able to leave through the alarmed front door and walk across the street off of the property before staff was able to follow and redirect R1 which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Repeat Violation-Civil Penalty Assessed.
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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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC9099 (FAS) - (06/04)

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