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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610046
Report Date: 03/30/2023
Date Signed: 03/30/2023 05:07:25 PM

Document Has Been Signed on 03/30/2023 05:07 PM - 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:HEARTLAND SENIOR LIVING AT SUNNYDALEFACILITY NUMBER:
567610046
ADMINISTRATOR:STRELLNER, JOHNFACILITY TYPE:
740
ADDRESS:704 ERRINGER RDTELEPHONE:
(805) 306-0021
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 4DATE:
03/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:John StrellnerTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management – Deficiencies visit to address a deficiency noted during a complaint investigation visit on 11/18/2022 regarding complaint control number 29-AS-20221110155812.

During the visit on 11/18/2022, LPA reviewed records for resident 1 (R1) and found the following:

R1 was admitted to the facility on 4/12/2022. A Functional Capacity Assessment was completed on 4/7/2022 and reviewed with R1’s responsible party (RP) on 4/8/2022. An Appraisal/Needs and Services Plan was only partially completed on 4/6/2022 with the RP.

The licensee had notified the RP by letter dated 8/31/2022 that the monthly rate would be increased by $1,500/month starting November 1, 2022, due to an increase in operating costs and an increase in R1’s care needs. The licensee did not meet with the RP nor complete an Appraisal/Needs and Services Plan outlining R1’s significant change in condition, increased care needs and their care plan.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).


Exit interview conducted. A copy of the report and appeal rights were emailed to the administrator.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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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Document Has Been Signed on 03/30/2023 05:07 PM - It Cannot Be Edited


Created By: Teresa Camara On 03/30/2023 at 01:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEARTLAND SENIOR LIVING AT SUNNYDALE
FACILITY NUMBER: 567610046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2023
Section Cited

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87467 Resident Participation in Decisionmaking (a) (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months, whichever occurs first.
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This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. The licensee failed to complete an appraisal/needs and services plan outlining a significant change in condition or meet with R1's RP to review the changes, which posed 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
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