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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360900455
Report Date: 10/22/2024
Date Signed: 10/22/2024 04:28:35 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2024 and conducted by Evaluator Sarina Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241018122741
FACILITY NAME:HERITAGE GARDENSFACILITY NUMBER:
360900455
ADMINISTRATOR:LEAK, LISAFACILITY TYPE:
740
ADDRESS:25271 BARTON RDTELEPHONE:
(909) 796-0219
CITY:LOMA LINDASTATE: CAZIP CODE:
92354
CAPACITY:64CENSUS: 55DATE:
10/22/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Jessica RamosTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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9
Staff do not ensure resident's needs are met.
INVESTIGATION FINDINGS:
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13
Licensing Program Analysts (LPAs) Sarina Ramirez ad Mary Rico conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegation. LPAs met with Administrator Jessica Ramos and explained the purpose of the visit.

Regarding the allegation above, LPA Ramirez and LPA Rico conducted 5 staff interviews. 5 out of the 5 staff informed LPA residents needs are being met. 3 out of the 5 staff stated to LPAs they encourage residents to be independent, but never refuse assistance.

LPA conducted 7 resident interviews. 2 out of the 7 residents stated staff are not ensuring residents needs are being met; 3 out of the 7 residents stated staff ensure their needs are being met, during the investigation 2 out of the 7 residents were unable to answer LPAs questions to corroborate the above allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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 56-AS-20241018122741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HERITAGE GARDENS
FACILITY NUMBER: 360900455
VISIT DATE: 10/22/2024
NARRATIVE
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Based on record review R1 care plan indicates R1 is independent and is encouraged for self- care tasks.

Based on LPAs observations, record review, and interviews, the above allegations are Unsubstantiated. A finding that complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.



An exit interview was conducted, and this report was discussed and provided to Administrator Jessica Ramos along with a copy of the appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2