425800777-10-18-2023-29-AS-KKOS-CWQKXQ-20231018081752

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800777
Report Date: 10/02/2023
Date Signed: 10/18/2023 08:18:23 AM

Document Has Been Signed on 10/18/2023 08:18 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 COMMUNITY		FACILITY NUMBER:	425800777
ADMINISTRATOR:	ROSEMARIE L. HARRIS		FACILITY TYPE:	740
ADDRESS:	5200 HOLLISTER AVE.		TELEPHONE:	(805) 967-2661
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	68	CENSUS: 56	DATE:	10/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Alejandra Nunez, Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. LPA arrived at 12:55 PM and was greeted by Front Desk Receptionist Staff 1 (S1). Administrator Alejandra Nunez was present during the inspection. At the time of arrival, there were 56 residents in care with 2 medication technicians, 6 caregivers, and 2 “Rap Aid” Hospice assistants, and 1 activities coordinator on duty. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a Dementia diagnosis, a Hospice Waiver for 25 residents, and is approved for delayed egress. Currently, there are 20 residents on hospice. Entrance interview conducted: A tour of the physical environment and accommodations were assessed. The following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the two-story facility for fire safety, personal accommodations and food service. The facility maintains a comfortable room temperature. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There are 16 fire extinguishers on the premises last serviced on 10/22/2022. There is a total of 78 dual carbon monoxide detectors/smoke alarms throughout the facility. The local fire department is alerted when/if the smoke alarms/carbon monoxide detectors are activated. Fire drills are conducted approximately twice each year. Residents participate at will in activities such as music and live entertainment, spiritual and religious activities, outings with family members, games, art activities, painting activities, storytelling, word games, travel shows, tri-shaw rides, van rides, and picnics to local parks and attractions. Additionally, the facility participates in the state-based Vitality program through the local community college. Activities are scheduled in the mornings, afternoons, and evenings. Evening activities were recently incorporated for all residents especially those who may experience sundowning behaviors. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
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.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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 HOUSE-AN ASSISTED LIVING COMMUNITY	FACILITY NUMBER: 425800777
	VISIT DATE: 10/02/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Snacks and beverages are available for residents in care upon request. LPA observed the kitchen area and dining areas to be clean. Cleaning agents and the toxic chemicals are kept in locked supply rooms throughout the facility.
The facility consists of four neighborhoods each conducive to the level of care required for the residents. All bedrooms have sufficient lighting, nightstands, beds, and bed furnishings. A locked medication cart is designated for each neighborhood in the Wellness Clinic. First aid supplies are also kept in the Wellness Clinic.
Neighborhood #4 is a neighborhood for residents who require a higher level of care. The facility maintains a higher staff ratio in Neighborhood #4 to meet the needs of the residents.
Throughout the neighborhoods, there are dining rooms, libraries, beauty salon, social seating areas, outdoor patios, and paved walkways conducive for leisure walks throughout the facility.
The physical environment was checked for cleanliness and condition. The facility was seen to be in good repair inside and outside.
First aid kit and additional first aid supplies are kept in a locked centrally stored cabinet in the Wellness Clinic, the Personal Care area, and in the kitchen.

Due to time restraints, LPA will return at a later date to continue the inspection.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
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

LIC809 (FAS) - (06/04)

Page: 2 of 2