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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800777
Report Date: 11/21/2023
Date Signed: 11/22/2023 09:59:20 AM

Document Has Been Signed on 11/22/2023 09:59 AM - 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 HOUSE-AN ASSISTED LIVING COMMUNITYFACILITY NUMBER:
425800777
ADMINISTRATOR:ROSEMARIE L. HARRISFACILITY TYPE:
740
ADDRESS:5200 HOLLISTER AVE.TELEPHONE:
(805) 967-2661
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY: 68CENSUS: 56DATE:
11/21/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:54 AM
MET WITH:Alejandra Nunez, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management - Annual Continuation visit to the facility above. LPA met with Administrator Alejandra Nunez and explained the purpose of the visit.

LPA reviewed Staff records for trainings, health screenings, and background checks.

LPA reviewed Residents' records for medication administration and medication record keeping. Technical Assistance was provided to include specific information on medication distribution such as start dates noted, Doctor’s changes noted, and care notes recorded.

Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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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