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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600805
Report Date: 04/16/2025
Date Signed: 04/16/2025 12:20:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/19/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250319150828
FACILITY NAME:HEIRLOOM GARDENS OF DALY CITYFACILITY NUMBER:
415600805
ADMINISTRATOR:DE LA TORRE, JOCELYNFACILITY TYPE:
740
ADDRESS:75 SURREY COURTTELEPHONE:
(650) 922-1039
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:6CENSUS: 0DATE:
04/16/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Licensee/administrator, Jocelyn De La TorreTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff restrained resident by tying resident's bedroom door to a handrail
INVESTIGATION FINDINGS:
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On April 16, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Licensee/administrator, Jocelyn De La Torre and explained the purpose of the visit.

Regarding the allegation, facility staff restrained resident by tying resident's bedroom door to a handrail, according to the reporting party, on 3/16/25, there was a fire at the facility and it was observed that there was a tie on Resident 1's (R1's) door handle on one side and it was tied to stair railing on opposing side.

During the investigation, LPA interviewed the administrator and interviewed staff. According to the administrator, she admitted that R1's room was tied by Staff 1 (S1), however does not know why. In addition, based on staff interviewed, S1 admitted that he/she did tie R1's room door because R1's room would not close all the way and to stop R1 from going downstairs all the time.

Based on the information collected, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Licensee/administrator, Jocelyn De La Torre and a copy is provided with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
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 2
Control Number 14-AS-20250319150828
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HEIRLOOM GARDENS OF DALY CITY
FACILITY NUMBER: 415600805
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2025
Section Cited
CCR
87468.1(a)(6)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night...

This regulation is not met as evidenced by:
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Licensee/administrator shall submit a plan in writing on how to ensure CCR 87468.1(a)(6) will be met. This plan shall include staff training.
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Based on interviews conducted, S1 admitted that he/she tied R1's door on 3/16/25, because R1's door did not close all the way and to stop R1 from going downstairs which poses an immediate health and safety concern to residents in care.
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Type A
04/17/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This regulation is not met as evidenced by:
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Licensee/administrator shall submit a plan in writing on how to ensure CCR 87468.1(a)(6) will be met. This plan shall include staff training.
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This regulation is not met as evidenced by:

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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2