360900455-4-6-2026-56-AS-KCLS-DSYT2G-20260409142042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 360900455
Report Date: 04/06/2026
Date Signed: 04/06/2026 11:35:30 AM

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
11/06/2025 and conducted by Evaluator Beena Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20251106142042

FACILITY NAME:	HERITAGE GARDENS		FACILITY NUMBER:	360900455
ADMINISTRATOR:	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: 57	DATE:	04/06/2026
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Facility administrator Jessica Ramos		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

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Staff neglect resulted in a resident sustaining multiple burns.
Staff did not timely address a resident's change in medical condition.

INVESTIGATION FINDINGS:

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On 04/6/2026,Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to the facility to deliver findings on a complaint alleging, Staff neglect resulted in a resident sustaining multiple burns and Staff did not timely address a resident's change in medical condition. LPA Singh met with front staff and was granted entry into the facility. LPA Singh was greeted by facility administrator Jessica Ramos and stated the purpose of this visit. The investigation conducted by LPA Singh consisted of observations,interviews and records review.

First Alegation:- Staff neglect resulted in a resident sustaining multiple burns.
LPA Singh met with the resident to discuss the accidental fire that led to their burn injuries and subsequent admission. The resident admitted that the incident occurred while they were receiving 2 liters of supplemental oxygen at the facility, explaining that they inadvertently attempted to light a cigarette after forgetting they were connected to the supply. R#1 self manage their oxygen and has quit smoking since the incident due to health reasons. This account was corroborated by the reporting party, who noted that the resident had previously been instructed not to smoke in the room while using oxygen.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20251106142042

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: 04/06/2026

NARRATIVE

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Despite the accident, the resident expressed satisfaction with the facility, describing the staff as attentive and stating there were no concerns regarding the quality of care or supervision provided.

Second Allegation:- Staff did not timely address a resident's change in medical condition.
LPA Singh conducted interviews with staff and residents concerning an un-witnessed fall involving Resident #1 (R1), which occurred while the resident was maneuvering a power chair outside the community while at the bank. Following the incident, the resident confirmed they were evaluated by facility personnel upon their return to the building. The resident further reported that staff provided the necessary medical attention to address the situation, ensuring their health and safety were prioritized after the fall. Statements from the resident, staff, and the reporting party consistently indicated that the facility provides adequate care and supervision, with no evidence of neglect or lack of oversight. Furthermore, Five (5)out of Five(5)residents and Three(3) out three(3) staff corroborated that the facility maintains a high standard of care, noting that personnel are attentive, assist in a timely manner, and respond appropriately to any changes in a resident's medical condition. Statements, records, and interviews obtained did not provide sufficient information to corroborate the allegation.

Based on the evidence found during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC9099, LIC9099 C were discussed and provided to Facility Administrator Jessica Ramos.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026

LIC9099 (FAS) - (06/04)

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