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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200506
Report Date: 12/30/2021
Date Signed: 12/30/2021 12:06:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2020 and conducted by Evaluator Gregory Clark
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200218094628
FACILITY NAME:HERITAGE HAVENFACILITY NUMBER:
019200506
ADMINISTRATOR:FERDINAND GUTIERREZFACILITY TYPE:
740
ADDRESS:389 JUANA AVENUETELEPHONE:
(510) 357-1300
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:27CENSUS: 18DATE:
12/30/2021
UNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Ferdinand GutierrezTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility has bed bugs.
INVESTIGATION FINDINGS:
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On 12/30/2021 LPA G. Clark and LPM Y. Flores-Larios arrived unannounced to deliver compliant findings. LPA and LPM met with Jhemierly Morales, Caregiver. Ferdinand Gutierrez, administrator arrived shortly after.

Based on interviews conducted with Administrator on 10/27/2021, there were a few cases of residents infested by bed bugs in the past but has been addressed. Administrator states that the facility has a contract with a pest control company that takes care of bed bugs and other pest issues. Administrator provided LPA a bed bug agreement with Clark Pest Control dated 12/13/19 indicating treatment for Rooms 10, 14 and 15. Based on interviews conducted by LPA with S2 and S3, S2 confirmed with LPA that there were residents and staff who were infested by bed bugs. S2 states that all residents’ bed frames were replaced with new ones. And that treatment of the rooms affected was completed.

Based on interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099D.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20200218094628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HERITAGE HAVEN
FACILITY NUMBER: 019200506
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2022
Section Cited
CCR
87303
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87303 Maintenance and Operation


(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Facility has contracted with a pest control company. Administrator will submit to CCL proof of service provided on a regular basis to make sure that there is a continuous pest control service provided to the facility starting with the latest service.
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Based on interviews conducted, Administrator failed to maintain facility for the safety and well-being of residents and staff. Residents and staff were infested with bed bugs which poses a potential risk to the health and safety of residents, staff and visitors.
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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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2