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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209251
Report Date: 12/21/2023
Date Signed: 12/21/2023 05:20:04 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/12/2023 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20231212104650
FACILITY NAME:HERITAGE CARE HOMEFACILITY NUMBER:
107209251
ADMINISTRATOR:KUMAR, ARUNFACILITY TYPE:
740
ADDRESS:167 W GOSHEN AVETELEPHONE:
(559) 473-8988
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Consulting House Manager (CHM) Phoeun MarezTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staffing requirements not being met
INVESTIGATION FINDINGS:
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An unannounced Complaint visit was conducted on the date & times indicated above by Licensing Program Analyst (LPA) K. McClurg. LPA was met @ door by caregiver, introduced self & asked is Administrator was available. Staff contacted Corporate Officer (CO) of Licensee Manpret Singh by telephone. LPA spoke with CO. CO stated that they would not be able to join LPA during visit, however Consulting House Manager (CHM) would be there shortly & is authorized to sign for receipt of report, as well & collaborate on Plan of Correction(s) (POC) for any citations/deficiencies issued.
-LPA reviewed resident records & discussed resident behavior with staff. Per Physician Reports & staff, current residents do not wander & do not have needs that would require awake staff. All resident bedroom doors are kept open, including Staff room door. Staff will check on residents during the night.
-The Department has investigated this allegation & determined it to be UNFOUNDED.
-Exit interview conducted with CHM. Copy of reports provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/12/2023 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20231212104650

FACILITY NAME:HERITAGE CARE HOMEFACILITY NUMBER:
107209251
ADMINISTRATOR:KUMAR, ARUNFACILITY TYPE:
740
ADDRESS:167 W GOSHEN AVETELEPHONE:
(559) 473-8988
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Consulting House Manager (CHM) Phoeun MarezTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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9
Facility mismanaged resident medications
Facility is not keeping accurate medication records
INVESTIGATION FINDINGS:
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Facility MARs indicate that Medication for Resident 1 (R1) was given after medication had ordered by hospice to be discontued (d/c). Dec 2023 indicated that medication Quetiapine 50mg for AM was giver to R1 on 12/8/23. 2nd page of MARs has hand written entry for same medication for PM initialed as being given on 12/9/23 & 12/10/23. Note on MARs indicated that hospice ordered d/c for Seroquel generic for Quetiapine on December 7, 2023
-MARs observed to be missing initials of medication given, including for morning on date of this visit.
-The Department has investigated the above allegations & found them to be SUBSTANTIATED.
-Deficiencies Issued. Exit interview conducted with CHM. Copy of reports provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20231212104650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HERITAGE CARE HOME
FACILITY NUMBER: 107209251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
87465(a)(5)
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Incidental Medical...Care.
A plan for incidental medical...care shall be developed by each facility. Facility staff...may assist persons with self-administration (of medication) as needed.
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CHM has agreed to submit a plan of how medication communication will be documented & handled in a timely manner, as well as maintaining correct med record keeping (MARs).
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Medication observed to be given past d/c date due to lack of plan.
MARs not being signed at time Rx given, requiring a plan to ensure records are maintained correctly @ all times.
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Plan to include brief outline to be shared with staff & date(s) staff will be trained. Facility to maintain personnel training documents..
POC may be emailed to the LPA by date indicated.
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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: See Moua
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3