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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413073
Report Date: 07/12/2023
Date Signed: 07/12/2023 12:45:04 PM

Document Has Been Signed on 07/12/2023 12:45 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: 50DATE:
07/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Assistant Administrartor Erika MontoyaTIME COMPLETED:
12:45 PM
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On 07/12/2023 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility for a Case Management Deficiency visit. LPA Brown identified herself and discussed the purpose of the visit with Assistant Administrator Erika Montoya.

During the facility on 07/12/2023, LPA Brown requested a copy of LIC500 Personnel Report from Assistant Administrator Erica Montoya and per LPA Brown’s review, LPA Brown observed Staff # 7 (S7) and Staff # 8 (S8) were working at the facility without criminal background clearance. Assistant Administrator Erika Montoya confirmed with LPA Brown that S7 had been employed since 06/2006 and S8 had been employed since 07/2021. LPA Brown explained to Assistant Administrator Montoya that deficiency will be issued as this pose immediate health, safety and personal rights risks to residents in care.



A civil penalty of $500.00 was assessed per individual for S7 and S8 working at the facility without criminal background clearance. The civil penalty will continue to be assessed of $100.00 per day until corrected during the visit.

An exit interview was conducted where this report, LIC809, along with LIC809D, LIC421BG and Appeal Rights were discussed and provided to Assistant Administrator Erika Montoya.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/12/2023 12:45 PM - It Cannot Be Edited


Created By: Melody Brown On 07/12/2023 at 12:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HERITAGE COURT ASSISTED LIVING
FACILITY NUMBER: 366413073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2023
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (1) Obtain a California clearance... This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87355(e)(1) and submit proof of Training Log to LPA Brown by POC due date.
Licensee stated to remove S7 and S8 immediately and submit proof of criminal background clearance to LPA Brown by POC due date.
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Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing S7 and S8 to work at the facility without criminal backround which pose immediate health, safety and personal rights risks to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


LIC809 (FAS) - (06/04)
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