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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200506
Report Date: 08/10/2023
Date Signed: 08/10/2023 01:57:59 PM

Document Has Been Signed on 08/10/2023 01:57 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 24DATE:
08/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Ferdinand Gutierrez, AdministratorTIME COMPLETED:
02:20 PM
NARRATIVE
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On 8/10/2023 at 11:10am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Ferdinand Guiterrez, Adminstrator, and explained the purpose of the visit.

While LPA L. Hall was conducting a complaint investigation (15-AS-20230807161348) on 8/10/2023, LPA toured the kitchen and garage of the facility. LPA also reviewed ten (10) resident files and three (3) staff files.
  • At 10:10am, LPA observed an unexplainable amount of flies on the porch. And when inside facility flies were everywhere.
  • At 10:22am, LPA observed a broken window and cabinet doors located in the kitchen.
  • At 10:25am, LPA observed the fire extinguisher was last serviced on 3/3/2020.
  • At 10:30am, LPA observed an exit door leading to the back was broken.
  • At 11:45pm, LPA observed during record review eight (8) of ten (10) physician reports was not current and eight (8) of the (10) appraisal needs and services plan was not current.
  • At 12:30pm, LPA observed during records review all three (3) staff does not have first aid or CPR certification.
  • At 12:30pm, LPA observed during record review that all three (3) staff do not have current required training.


Continued on LIC809.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 08/10/2023
NARRATIVE
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Continued from LIC809.

LPA is requesting the following documents to be submitted to CCLD by 8/17/2023.
  • Liability insurance
  • Emergency disaster plan (LIC610E)
  • Surety bond
  • LIC500 (Personnel record)
  • LIC308 (Designation of facility responsibility)


Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of, appeal rights, and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 08/10/2023 01:57 PM - It Cannot Be Edited


Created By: Laura Hall On 08/10/2023 at 12:53 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HERITAGE HAVEN
FACILITY NUMBER: 019200506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
CCR
87303(a)

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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. This requirement was not met as evidence by:
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Administrator agreed to have window, door, cabinet fixed, and rid excesive amount of flies. Administrator will submit photo for all, and either purchase insect kill or hire an exterminator. Send photos to CCLD by POC date.
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Based on LPA observation the Licensee did not comply with the section cited above in having the in good repair and free of unexplainable amount of flies, which poses a potential health and safety risk to persons in care.
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Type B
08/10/2023
Section Cited
CCR87203

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidence by:
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Administrator agreed to either purchase or have fire extinguishers serviced and submit a copy of receipt to CCLD by POC date.
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Based on LPA observation the Licensee did not comply with the section cited above in having the fire extinguishers currently serviced or purchased, which poses a potential health and safety risk to persons 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 08/10/2023 01:57 PM - It Cannot Be Edited


Created By: Laura Hall On 08/10/2023 at 01:21 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HERITAGE HAVEN
FACILITY NUMBER: 019200506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
CCR
87463(c)

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87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any,... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, This requirement is not met as evidence by:
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Administrator agreed to update all appraisal needs and services plan and to obtain a current physician report for the residents that need it and submit a self-certification that it has been completed to CCLD by POC date.
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Based on LPAs record review the Licensee did not comply with the section cited above in having current appraisal needs and services or physician's report, which poses potential health and safety risk to persons in care.
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Type B
08/17/2023
Section Cited
CCR87411(c)(1)

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87411 Personnel Requirements - General (c)All RCFE staff... shall receive initial and annual training...
(1) Staff... shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirment was not met as evidence by:
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Administrator agreed to have all staff current first aid certification and submit a copy of certification to CCLD by POC date.
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Based on LPAs record review the LIcensee did not comply with the section cited above in having all staff firs aid certified and at least 1 staff per shift CPR certified, which poses a potential health and safety risk for persons 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 08/10/2023 01:57 PM - It Cannot Be Edited


Created By: Laura Hall On 08/10/2023 at 01:38 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HERITAGE HAVEN
FACILITY NUMBER: 019200506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
HSC
1569.625(b)(2)

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1569.625 (2) In addition to paragraph (1), training requirements shall also include... 20 hours annually, eight hours of... dementia care training... and four hours.. to postural supports, restricted health conditions, and hospice car.... This training shall be... on the job, or in a classroom, and may include online training. This requirement was not met as evidence by:
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Administrator agreed to have all staff conduct their annual training and submit self-certification to CCLD that it has been completed by POC date.
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Based on LPAs record review the Licensee did not comply with the section cited above in having staff currently trained, which poses a potential health and safety risk to persons 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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