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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507005194
Report Date: 10/25/2022
Date Signed: 10/25/2022 10:47:14 AM


Document Has Been Signed on 10/25/2022 10:47 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:HERITAGE HOMEFACILITY NUMBER:
507005194
ADMINISTRATOR:ROBERT L. IRWIN, JR.FACILITY TYPE:
740
ADDRESS:943 TERRACE COURTTELEPHONE:
(209) 845-2712
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY:6CENSUS: 5DATE:
10/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Mavis Irwin - Licensee/AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Case Management Incident Visit. LPA explained purpose of visit with Licensee/administrator.

There were several incidents self-reported by administrator to Community Care Licensing and submitted on 10/20/2022. The incidents involved personal rights with Staff (1) and two residents. There are no specific dates when the incidents occurred, but Licensee took immediate action and S1 was terminated on 10/20/2022.

There was one deficiency cited during today’s inspection from California Code of regulations, Title 22.

Exit interview conducted with Licensee and copies of reports/appeal rights left with Licensee.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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


Document Has Been Signed on 10/25/2022 10:47 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: HERITAGE HOME
FACILITY NUMBER: 507005194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2022
Section Cited

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87468.1(a) (1) Personal Rights of Residents in All Facilities
Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidenced by:
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Licensee reported several incidents that involved a lack of dignity in personal relationships with S1 and residents. This poses a potential health and safety risk to residents 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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2