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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200506
Report Date: 04/28/2026
Date Signed: 04/28/2026 11:30:59 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
04/01/2026 and conducted by Evaluator Yasamin Brown
COMPLAINT CONTROL NUMBER: 15-AS-20260401142902
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: 19DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Ferdinand Gutierrez, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
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9
Staff are not providing adequate supervision to the residents in care.
INVESTIGATION FINDINGS:
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On 4/28/2026 at 9:25 AM, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Ferdinand G, Administrator and explained the purpose of the visit.

During the course of investigation, LPA obtained the following documents for R1: LIC602 (Medical Assessment), Identification and Emergency Contact, Functional Capability and Appraisal Needs and Services Plan. LPA obtained the following documents: Resident Roster and the LIC500 (Personnel Report). LPA also conducted interviews with S1 and R1.

Continue on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
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-20260401142902
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HERITAGE HAVEN
FACILITY NUMBER: 019200506
VISIT DATE: 04/28/2026
NARRATIVE
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Continued from LIC9099.

Allegation: Staff are not providing adequate supervision to the residents in care.

Finding: Unsubstantiated


During record review and interview, LPA discovered that R1 can leave the facility unassisted based on their LIC602 (Physicians report) dated 4/26/2023. S1 stated that R1 is able to leave the facility unassisted and has spoke with neighbors concerning residents leaving the facility.

Based on the investigation, which included interviews of 1 staff and 1 resident, and review of supervision log/sign in sheet, the allegation that Staff are not providing adequate supervision to the residents in care, is unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.


Exit Interview conducted with Ferdinand and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2