300607488-3-25-2026-22-AS-APAO-DSK3T7-20260326183126

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300607488
Report Date: 03/25/2026
Date Signed: 03/25/2026 03:03:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2024 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240322140918

FACILITY NAME:	HERITAGE POINTE		FACILITY NUMBER:	300607488
ADMINISTRATOR:	JONATHAN PERLES		FACILITY TYPE:	740
ADDRESS:	27356 BELLOGENTE		TELEPHONE:	(949) 364-9685
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	225	CENSUS: 102	DATE:	03/25/2026
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Georgianna Mendez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff neglect resulted in a resident sustaining an injury from multiple falls
Staff left a resident unattended while being transported to the hospital

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above and delivering findings to the licensee. LPA was greeted and granted entry by facility staff after introducing themselves and stating the reason for the visit. Administrator Georgianna Mendez was present on the premises and assisted with the visit after being presented with the four allegations under review.

The initial complaint investigation visit was conducted on March 28, 2024. During the visit, LPA requested and obtained records maintained at the facility for resident R1. A follow-up visit took place on July 22, 2025, with additional records requested. Additional interviews attempted or conducted during the investigation.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

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 6

Control Number 22-AS-20240322140918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HERITAGE POINTE	FACILITY NUMBER: 300607488
	VISIT DATE: 03/25/2026

NARRATIVE

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Resident R1 was admitted to the facility on September 30, 2013 with a primary diagnosis of hypertension and no initial indication of major neurocognitive disorders at the time of admission. R1 was discharged from the facility on January 9, 2024.

Regarding the allegation that Staff neglect resulted in a resident sustaining an injury from multiple falls: Based on the evidence gathered, there have been multiple instances of fall incidents sustained by R1, at least one of which resulted in injury and hospital treatment. The evidence gathered is however insufficient to clearly establish that the falls were attributable to staff neglect rather than to changes in the resident’s condition. The allegation is therefore found to be Unsubstantiated.

Regarding the allegation that Staff left a resident unattended while being transported to the hospital, the following has been concluded: After a fall sustained on December 8, 2023, R1 was first transported via EMS to Hoag Hospital in Irvine before being transferred to Hoag Hospital Newport Beach at the neurosurgery department due to a suspicion of a subdural hematoma. A review of the resident records maintained at the facility also allowed LPA to corroborate that the responsible party for the resident had been contacted by the facility staff following the fall. A fax reporting the fall to the resident's physician was also located. Report states that EMS had initially informed the facility that the resident would be transported to Saddleback MemorialCare but was re-routed to Hoag Irvine for unknown reasons which appears to explain why R1’s responsible party had to actively attempt to locate the resident following admission. A copy of R1’s Consent for Emergency Medical Treatment was present and on file.
As resident was placed under the responsibility of EMS personnel, the allegation is found to be Unsubstantiated, meaning 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.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2024 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240322140918

FACILITY NAME:	HERITAGE POINTE		FACILITY NUMBER:	300607488
ADMINISTRATOR:	JONATHAN PERLES		FACILITY TYPE:	740
ADDRESS:	27356 BELLOGENTE		TELEPHONE:	(949) 364-9685
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	225	CENSUS:	DATE:	03/25/2026
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Georgianna Mendez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not provide adequate care and supervision to a resident
Staff did not properly report incidents involving a resident

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 22-AS-20240322140918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HERITAGE POINTE	FACILITY NUMBER: 300607488
	VISIT DATE: 03/25/2026

NARRATIVE

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Resident R1 was admitted to the facility on September 30, 2013 with a primary diagnosis of hypertension and no initial indication of major neurocognitive disorders at the time of admission. Subsequent appraisals were conducted and reviewed, including updates to R1’s plan of care dated June 22 and August 23, 2023.
Per a review of available charting notes, over a period starting in May 2023 and ending with the resident’s discharge in January 2024, R1 sustained at least five separate fall incidents. A significant bruise on R1's buttocks was reported to the family and primary care provider on August 25, 2023 with no ability to clearly determine the origin of the bruise. On that day, R1 was sent to Mission Hospital via 911 for generalized weakness and low food/drink intake and diagnosed with acute kidney injury. No report on file submitted to the Orange County Regional Office. Another reported fall occurred on November 7, 2023, with facility staff indicating resident had lost their balance but were assessed to not present any injury or pain. Fall also not reported to the Department of Social Services per a review of Incident Reports on file. R1 sustained another fall on December 8, 2023 and was first transported via EMS to Hoag Hospital in Irvine before being transferred to Hoag Hospital Newport Beach at the neurosurgery department due to a suspicion of a subdural hematoma. A review of the resident records maintained at the facility also allowed LPA to corroborate that the responsible party for the resident had been contacted by the facility staff following the fall. A fax reporting the fall to the resident's physician was also located. Report states that EMS had initially informed the facility that the resident would be transported to Saddleback MemorialCare but was re-routed to Hoag Irvine for unknown reasons which appears to explain why R1’s responsible party had to actively attempt to locate the resident following admission. Finally, another fall incident, this time not resulting in significant injury also appeared to be documented on January 8, 2024 and reported to the resident's primary care physician and responsible party but not to the Department of Social Services. R1 were discharged to their authorized representative on January 9, 2024.

Regarding the allegation that Staff did not provide adequate care and supervision to a resident, the following has been concluded: Despite multiple occurrences of fall incidents sustained by R1, the individual needs assessments conducted by facility staff on June 22 and August 23, 2023 fail to document the fact that the resident was at risk for falls. Furthermore, the evolution of R1’s Mild Cognitive Impairment to a documented diagnosis of dementia was not apparent in the physician until after the resident was hospitalized, in spite of signs and incidents occurring in the months leading to the emergency hospitalization.

Continued on LIC9099-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 22-AS-20240322140918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HERITAGE POINTE	FACILITY NUMBER: 300607488
	VISIT DATE: 03/25/2026

NARRATIVE

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Regarding the allegation that Staff did not properly report incidents involving a resident, the following has been concluded: No reports were made to the Orange County Regional Office during any of the documented fall or hospitalization incidents sustained by R1 in 2023 and 2024.

As a result, both allegations are found to be Substantiated, meaning that the preponderance of the evidence standard has been met.

Two deficiencies to Title 22 requirements are being cited on an attached form LIC9099-D
.
An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 22-AS-20240322140918

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HERITAGE POINTE	FACILITY NUMBER: 300607488
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/01/2026 Section Cited CCR 87463(b)	1 2 3 4 5 6 7	Per CCR 87463(b), “the reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition”. This requirement is not met as evidenced by: Based on records reviewed, R1 was never assessed to be a fall risk in spite of	1 2 3 4 5 6 7	Licensee agrees to review section cited and submit proof before the plan of corrections due date.
	8 9 10 11 12 13 14	multiple occurrences of falls between May 2023 and January 2024, at least one of which resulted in an injury. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.	8 9 10 11 12 13 14
Type B 04/01/2026 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	Per CCR, “Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency (…) within seven days of the occurrence of any of the events specified in (A) through	1 2 3 4 5 6 7	Licensee agrees to review reporting requirements and submit proof before the plan of corrections due date.
	8 9 10 11 12 13 14	(D) below. (D) Any incident which threatens the welfare, safety or health of any resident (…)” This requirement was not met as evidenced by: Multiple fall incidents including instances that resulted in injury and/or hospitalization were not reported to the Department. This constitutes a potential	8 9 10 11 12 13 14	risk to the health, safety and personal rights of individuals in care.

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: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026

LIC9099 (FAS) - (06/04)

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