360900455-2-25-2025-56-AS-SRAZ-DE8VUB-20250225154429

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360900455
Report Date: 02/25/2025
Date Signed: 02/25/2025 03:44:38 PM

Document Has Been Signed on 02/25/2025 03:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR/ DIRECTOR:	JESSICA J. RAMOS		FACILITY TYPE:	740
ADDRESS:	25271 BARTON RD		TELEPHONE:	(909) 796-0219
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY: 64		CENSUS: 51	DATE:	02/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:05 PM
MET WITH:	Director of Operations Samuel Goings		TIME VISIT/ INSPECTION COMPLETED:	03:55 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano made an unannounced visit to the facility to conduct a required annual inspection. LPAs met Director of Operations Samuel Goings, and discussed the purpose of the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (62), and a current census of (51). LPAs conducted a general inspection of facility, which included, but was not limited to, the following:

Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pool or similar bodies of water. The facility has sufficient space for resident activities. Four (4) resident bedrooms and Four (4) resident’s bathrooms were inspected, hot water temperature measured at 105.9 degrees F. The facility is equipped with operating smoke/carbon monoxide alarms, laundry equipment, and telephone service. The facility has posted in a common area, personal rights, facility sketch, the Community Care Licensing complaint poster, Ombudsman poster, menu, activities, and license. Cleaning supplies and sharps were kept inaccessible to residents in care. Last fire drill was conducted 02/12/25.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply is sufficient for number of residents in care. Facility refrigerators and freezers were maintained in operating condition. The facility has posted a weekly menu.

Health Related services: LPAs reviewed four (4) resident medications. Resident’s medications are labeled and centrally stored in a locked room; however staff are not administering medications at prescribed times or signing after administering; deficiency will be issued.

Continuation on LIC809-C

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/25/2025

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Record Review: Seven (7) resident files reviewed were observed to be complete. Seven (7) staff files reviewed were observed to be incomplete, S1 had a missing health screening report signed by a physician, technical violation will be issued.

Based on LPAs observations and records reviewed, deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report (LIC809) and LIC 809D was discussed to Director of Operations Samuel Goings. Copies of the reports were provided with appeal rights to the Director of Operations at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/25/2025 03:44 PM - It Cannot Be Edited

Created By: Sarina Ramirez On 02/25/2025 at 03:27 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HERITAGE GARDENS	FACILITY NUMBER: 360900455
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not administering medication at the prescribed times, and not signing after administering which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/05/2025
	Plan of Correction
1 2 3 4	Administrator has agreed to conduct a training for staff on medication distribution, as well as staff have read and understand the regulation with signatures, provide proof of training to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Karen Clemons

LICENSING EVALUATOR NAME:

Sarina Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC809 (FAS) - (06/04)

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