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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200506
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:53:23 PM

Document Has Been Signed on 09/10/2024 02:53 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HERITAGE HAVENFACILITY NUMBER:
019200506
ADMINISTRATOR/
DIRECTOR:		FERDINAND GUTIERREZFACILITY TYPE:
740
ADDRESS:389 JUANA AVENUETELEPHONE:
(510) 357-1300
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 27CENSUS: 18DATE:
09/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Ferdinand Gutierrez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 09/10/2024 at 1:20 PM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding information obtained that a resident was missing. LPA met with Administrator, Ferdinand Gutierrez and explained the purpose of the visit.

LPA L. Alexander interviewed S1 that confirmed that R1 was missing on 09/05/2024 and returned back to the facility on 09/06/2024. S1 stated that R1 leaves almost everyday since they were admitted which was 08/13/2024. However, on this particular day, R1 did not return. S1 stated that R1 got lost. LPA interviewed R1 and R1 stated that they got lost but came back to the facility on the bus. R1's Physician's Report indicates that they are able to leave the facility unassisted. S1 stated that they will send an incident report via e-mail to Community Care Licensing (CCLD).

LPA L. Alexander collected the following documents:
Current Resident Roster and R1's Physician's Report.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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 09/10/2024 02:53 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 09/10/2024 at 02:24 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: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2024
Section Cited
CCR
87466

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87466 Observation of the Resident..The licensee shall ensure that residents are regularly observed...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
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Administrator will do an reappraisal with R1's physician and submit an updated re-appraisal and Physician's Report to CCLD by POC date.
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Based on interview, the licensee did not comply with the section above for not doing an updated reappraisal with the changes in R1 getting lost when leaving the facility. This posed a potential health and safety risk to person 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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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