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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413073
Report Date: 04/03/2023
Date Signed: 04/03/2023 02:11:01 PM

Document Has Been Signed on 04/03/2023 02:11 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
, 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: DATE:
04/03/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Janet Nelson - Wellness DirectorTIME COMPLETED:
02:11 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced collateral visit to this facility in relation to complaint control number: 18-AS-20200724130142. LPA met with Wellness director Janet Nelson and explained the nature of the visit.

LPA conducted witness interviews and obtained relevant documents. A copy of this report was reviewed with and provided to assistant administrator Erika Montoya at the conclusion of this visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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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