360900455-4-17-2026-56-AS-KCLS-DTDUSX-20260422155104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 360900455
Report Date: 04/17/2026
Date Signed: 04/17/2026 01:40:03 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
09/27/2024 and conducted by Evaluator Sarina Ramirez

COMPLAINT CONTROL NUMBER: 56-AS-20240927152021

FACILITY NAME:	HERITAGE GARDENS		FACILITY NUMBER:	360900455
ADMINISTRATOR:	LEAK, LISA		FACILITY TYPE:	740
ADDRESS:	25271 BARTON RD		TELEPHONE:	(909) 796-0219
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	64	CENSUS: 56	DATE:	04/17/2026
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Administrator Jessica Ramos		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained an unexplained head injury resulting in death.
Staff did not inform resident's responsible party of incident in a timely manner.
Staff did not seek timely medical care for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to deliver findings on the allegations mentioned. LPA met with Administrator Jessica Ramos and explained the purpose of the visit. The Department's investigation involved interviews and records review.

Allegation #1- Resident sustained an unexplained head injury resulting in death.
Resident #1 (R1) resided at Heritage Gardens Facility. During R1’s residency, R1 sustained an unwitnessed fall. Based on information obtained during the investigation, the fall is believed to have occurred while R1 was attempting to use their wheelchair for mobility assistance. As a result of the incident, R1 sustained bruising to their head and multiple lacerations to their arms. Emergency medical services were contacted, and R1 was transported to Loma Linda University Medical Center for evaluation and treatment. R1 remained hospitalized for four (4) days. During the hospital stay, medical records were reviewed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

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-20240927152021

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: 04/17/2026

NARRATIVE

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Findings indicated that R1 experienced respiratory complications. A CT scan revealed no abnormalities to the carotid arteries; however, documentation noted a blockage of the internal carotid artery. This condition is associated with an increased risk of neurological impairment, including stroke. Medical review further indicated that R1 had pre-existing conditions. There was no documentation indicating trauma or suspicious activity related to the fall. The attending physician did not attribute R1’s death to the fall.

During the investigation, records review and staff interviews were conducted. Documentation reviewed indicated the facility followed the resident’s care plan. The facility implemented measures to address fall risk, including coordination with R1’s private insurance to request additional interventions, such as a bed alarm. At the time of the incident, alarms were in place and operational. Staff conducted routine checks, assisted with medication management, and addressed R1’s mobility needs, including the use of a wheelchair for transfers. On the day of the incident, documentation revealed that R1 received their prescribed medications, and routine checks were completed by staff.

Based on the information obtained, there is insufficient evidence to support the allegation that the facility failed to provide adequate care and supervision. The allegation of neglect/lack of care and supervision is Unsubstantiated.

Allegation #2 - Staff did not inform resident's responsible party of incident in a timely manner.

Department staff conducted the investigation and revealed that at the time of the incident, the facility’s Medication Technician (Med-Tech) was notified by R1’s roommate that R1 had fallen. The Med-Tech responded immediately to the room and observed R1 on the floor. The MedTech initiated emergency response procedures. Vital signs were checked, and R1’s level of consciousness was evaluated. Emergency medical services were contacted without delay.

Based on the information obtained, there is insufficient evidence to support the allegation that the facility failed to inform responsible parties in a timely manner. The allegation is Unsubstantiated.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20240927152021

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: 04/17/2026

NARRATIVE

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Regarding allegation #3 - Staff did not seek timely medical care for resident.

Records reviewed during the investigation documented a dispatch time of 2101 hours. This documentation is consistent with staff statements and supports that emergency medical services were contacted promptly following the incident. The facility staff made timely notifications to the resident’s responsible party, and to the resident’s private insurance provider to address any additional preventive measures related to the incident.

Based on the information obtained, the facility responded promptly and appropriately to the incident, including immediate assessment, timely contacting of emergency medical services, and required notifications. The allegation of neglect/lack of care and supervision is Unsubstantiated.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Sarina Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

LIC9099 (FAS) - (06/04)

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