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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200506
Report Date: 10/17/2024
Date Signed: 10/17/2024 11:41:22 AM

Document Has Been Signed on 10/17/2024 11:41 AM - 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: 19DATE:
10/17/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:09 AM
MET WITH:Ferdinand Gutierrez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 10/17/2024 at 11:05 am Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Plan of Correction (POC) visit regarding Case Management visit on 09/10/2024. LPA met with Administrator, Ferdinand Gutierrez and explained the purpose of the visit.

On 09/10/2024, LPA conducted an Case Management visit in which deficiency were cited. The POC due date was 10/08/2024.

Deficiency not cleared during visit:
  • 87466 $100.00 x 9 Days = $900.00

Civil Penalties in the total amount of $900.00 is assessed today for failure to meet POC date for deficiency. Facility is subject to ongoing daily civil penalties until deficiency is corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.


SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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