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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413073
Report Date: 07/01/2021
Date Signed: 07/01/2021 03:48:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/22/2021 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210222101836
FACILITY NAME:HERITAGE COURT ASSISTED LIVINGFACILITY NUMBER:
366413073
ADMINISTRATOR:SCHLOTTMAN, JACOBFACILITY TYPE:
740
ADDRESS:275 GARNET WAY BTELEPHONE:
(909) 204-5000
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY:88CENSUS: 59DATE:
07/01/2021
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Erika MontoyaTIME COMPLETED:
04:03 PM
ALLEGATION(S):
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9
Facility is not following resident's doctor's orders.
Facility is not properly maintaining resident's medical device.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Anna Bueno and Natalie Gayoso conducted an unannounced visit to the facility to follow up on a complaint investigation and deliver findings. LPAs met with Erika Montoya, Assistant Administrator. The investigation consists of staff and resident interviews and review of pertinent documents.

The complaint alleges that 1: Facility is not following doctor’s orders and 2: Facility is not properly maintaining resident’s medical device. Interview with resident (R1) revealed that they have been prescribed a CPAP machine from a previous skilled nursing facility (SNF) and brought the machine to Heritage Court when they moved. R1 shared that two staff have assisted R1 with setting up the CPAP, cleaning the machine on multiple occassions, and using the recommended distilled water for the machine. R1 confirmed the bottle of distilled water that staff bought is still in R1’s room and that this facility has been following R1’s doctor’s orders regarding R1’s CPAP. These two allegations are therefore unsubstantiated per LPAs resident interview.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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 18-AS-20210222101836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HERITAGE COURT ASSISTED LIVING
FACILITY NUMBER: 366413073
VISIT DATE: 07/01/2021
NARRATIVE
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A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies have been cited during this visit. An exit interview and a copy of the report was given to Ms. Montoya.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2