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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413073
Report Date: 10/25/2021
Date Signed: 10/25/2021 03:26:31 PM

Document Has Been Signed on 10/25/2021 03:26 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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: 55DATE:
10/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Erika Montoya - Assistant AdministratorTIME COMPLETED:
03:29 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain. LPA met with Assistant Administrator Erika Montoya who confirmed there is no active/suspected Covid-19 case and/or exposure in the community. LPA toured the facility with Montoya.

The facility submitted a mitigation plan to Community Care Licensing (CCL) to mitigate the spread of COVID-19 in the facility. Single entry point at the skilled nursing facility lobby maintains the sign-in policy for universal entry screening. The facility also documents temperature and COVID-19 symptom checks for all visitors while residents are subject to regular observations for any change in condition. Continued weekly routine testing for staff is still observed. LPA observed all staff are properly fitted with face coverings.

LPA Bueno and Montoya toured the facility’s common rooms and an empty private apartment currently housing Personal Protective Equipment (PPE) . LPA and Montoya observed COVID precautionary signages around the facility. Montoya verified that the smoke and carbon monoxide detectors and fire alarms are maintained by an outside vendor and was last serviced in 8/13/2021. Montoya confirmed that fire extinguishers are checked quarterly by a different vendor. Montoya stated that the facility also routinely monitors the detectors for functionality. LPA observed hand sanitizer throughout the facility, mostly situated by the elevator and exit doors. Montoya confirmed the facility has an adequate supply of cleaning and disinfectant provisions.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was also provided to Montoya at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2021
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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