507005194-6-9-2023-27-AS-KHOS-CTFHVT-20230705063229

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507005194
Report Date: 06/08/2023
Date Signed: 06/09/2023 10:17:42 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2023 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20230207104923

FACILITY NAME:	HERITAGE HOME		FACILITY NUMBER:	507005194
ADMINISTRATOR:	ROBERT L. IRWIN, JR.		FACILITY TYPE:	740
ADDRESS:	943 TERRACE COURT		TELEPHONE:	(209) 845-2712
CITY:	OAKDALE	STATE: CA	ZIP CODE:	95361
CAPACITY:	6	CENSUS: 0	DATE:	06/08/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Mavis Irwin, Licensee		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not seek medical attention for resident.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 06/08/2023 by Licensing Program Analysts (LPAs) Kimberly Viarella and Charlie Yang who were met by the facility designated Administrator, Mavis Irwin.
Current census was 0 residents.

The purpose of this visit was to deliver the findings from this complaint investigation for the above allegations at this time.

Based upon the information gathered through interviews and records review, this LPA found that hospice was contacted for a lift assist. A review of records revealed that residents sometimes would fall or slide out of bed and hospice would be contacted for the lift assist and to determine if any additional medical interventions were necessary. This was demonstrated through interviews and records review.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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 27-AS-20230207104923

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HERITAGE HOME	FACILITY NUMBER: 507005194
	VISIT DATE: 06/08/2023

NARRATIVE

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As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited during today's complaint visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC9099 (FAS) - (06/04)

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