366413073-7-1-2021-18-AS-EMAN-C86NGN-20211026102723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366413073
Report Date: 07/01/2021
Date Signed: 07/01/2021 03:54:42 PM

Unfounded

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
03/01/2021 and conducted by Evaluator Natalie Gayoso

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210301133144

FACILITY NAME:	HERITAGE COURT ASSISTED LIVING		FACILITY NUMBER:	366413073
ADMINISTRATOR:	SCHLOTTMAN, JACOB		FACILITY TYPE:	740
ADDRESS:	275 GARNET WAY B		TELEPHONE:	(909) 204-5000
CITY:	UPLAND	STATE: CA	ZIP CODE:	91786
CAPACITY:	88	CENSUS: 59	DATE:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Erika Montoya		TIME COMPLETED:	04:03 PM

ALLEGATION(S):

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Facility accepted a resident with unstageable wound
Facility failed to obtain medical attention for resident

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Natalie Gayoso and Anna Bueno conducted a complaint visit to deliver findings regarding the above allegations. LPAs identified themselves and discussed the purpose of today’s visit and the elements of the above allegations with Assistant Administrator Erika Montoya.

The Department conducted investigation of the allegations to include interviews and records review. The first allegation indicates facility accepted a resident with unstageable wound. Interviews with staff revealed the facility did accept Resident 1 (R1) on 1/15/21 who had a stage 4 wound. Interview with Staff 1 (S1) stated the facility is aware that they are not able to admit residents with stage 2 or higher wounds unless hospice is involved and is providing wound care. Interview with Staff 2 (S2) stated hospice care was already in place and coordinated prior to R1 being admitted to the facility, and services started the same day R1 was admitted. LPA was able to confirm that a hospice care plan was in place prior to resident moving in. LPA reviewed facility file and verified the facility has a hospice waiver for 7.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Natalie Gayoso
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)

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Control Number 18-AS-20210301133144

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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The second allegation indicates the facility failed to obtain medical attention for resident. Interview with S2 stated R1 received wound care up to three times a week from hospice and was assessed twice by wound specialist, Wound Pros, on 1/19/21 and 2/19/21. Review of records confirmed R1 was receiving wound care two to three times a week from hospice and a plan of care was provided by Wound Pros

Based on the investigation the Department has found the allegations to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without reasonable basis.

An exit interview was conducted and a copy of this report was provided to Ms. Montoya.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Natalie Gayoso
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)

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