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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413073
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:33:49 PM

Substantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2023 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230731093552
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: 51DATE:
11/06/2023
UNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Assistant Administrator Lauren CalvaniTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff do not maintain facility in a clean and sanitary condition.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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On 11/06/2023 at 09:37 AM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott arrived unannounced at the facility to deliver findings for the allegations listed above. LPAs Brown and Wolcott were greeted and granted entry by a staff at the reception area and were informed that Assistant Administrator Lauren Calvani was on a meeting and will be informed of the visit. LPAs Brown and Wolcott explained the purpose of the visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

Through the information gathered during the investigation, it was confirmed by observation, documents review and interviews that the staffs do not maintain the facility in a clean and sanitary condition. Interviews with Resident #5 (R5), Resident #6 (R6), and Resident #8 (R8) indicated that their rooms gets clean once per week, staff missed days cleaning residents room and nobody cleans their room if the housekeeping staff's off. R10 reported to LPA Brown that no staff cleans their room and they had to clean it themselves.
***Continuation in LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
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 6
Control Number 56-AS-20230731093552
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
, CA 92507
FACILITY NAME: HERITAGE COURT ASSISTED LIVING
FACILITY NUMBER: 366413073
VISIT DATE: 11/06/2023
NARRATIVE
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Interviews with Staff #4 (S4) indicated that housekeeping staff should be cleaning residents room everyday. Staff #6 (S6) reported to LPAs Brown and Wolcott that only one (1) housekeeping staff works at the facility per day and Staff #7 indicated that First (1) floor of the facility's not clean and sanitary. In addition, interviews with S6 revealed that Staff #8 (S8) who was assigned to clean the first floor of the facility just sits, don't clean and they reported S8 to the housekeeping supervisor but the housekeeping supervisor did not do a thing to address the issue. During the facility visit on 11/06/2023, LPAs Brown and Wolcott toured the facility and observed that residents unkept rooms, not clean rooms, dirty carpets located at the first floor of the facility. Deficiencies will be issued as this pose potential health, safety and personal rights risks to residents in care.

The second allegation indicates Facility is in disrepair. LPAs Brown and Wolcott obtained evidence to corroborate the allegation. Interviews with Resident #2 (R2) indicated that the toilet was clogged in Room #103 and flooded Room #104 to Room #119, Resident #10 (R10) reported that their air conditioning unit was leaking and there's water on the floor. Interviews with Staff #4 (S4) indicated that Their Medical Room ceiling was collapsing and their sink was dripping. Moreover, Staff # 6 (S6) reported to LPAs Brown and Wolcott that the bathroom located near the facility's Dining Room was clogged for three (3) to four (4) months now. Also, Staff #7 (S7) reported to LPAs Brown and Woilcott sink leaking, and problem with the facility's vent. During the visit, LPAs Brown and Wolcott observed broken closet door in Room #117.

LPA Brown reviewed compliance history and observed that the facility’s issued the same deficiency for the facility not being clean and sanitary and in good repair on 07/14/2023. Civil Penalty was assessed for repeat violations within a 12-month period in the amount of $250.00 per citation and will continue to be assessed of $100.00 per day per citation until corrected.

Based on LPAs Brown and Wolcott's observations, interviews and records review, the preponderance of evidence standard has been met, and therefore the above allegation of Staff do not maintain facility in a clean and sanitary condition (Allegation #1), and Facility is in disrepair (Allegation #2) were found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is cited on the attached LIC9099D.
***Continuation in LIC9099C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 56-AS-20230731093552
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
, CA 92507
FACILITY NAME: HERITAGE COURT ASSISTED LIVING
FACILITY NUMBER: 366413073
VISIT DATE: 11/06/2023
NARRATIVE
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An exit interview was conducted where this report (LIC9099), LIC9099D,LIC421FC and Appeal Rights were discussed and provided to Assistant Administrator Lauren Calvani.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2023 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230731093552

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: 52DATE:
11/06/2023
UNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Assistant Administrator Lauren CalvaniTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Facility has mold.
INVESTIGATION FINDINGS:
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On 11/06/2023 at 09:37 AM, Licensing Program Analysts (LPAs) Melody Brown and Bianca Wolcott arrived unannounced at the facility to deliver findings for the allegation listed above. LPAs Brown and Wolcott were greeted and granted entry by a staff at the reception area and were informed that Assistant Administrator Lauren Calvani was on a meeting and will be informed of the visit. LPAs Brown and Wolcott explained the purpose of the visit. The investigation consisted of observation, interviews and a review of pertinent documentation.

The investigation was conducted by LPAs Melody Brown and Bianca Wolcott. The investigation consisted of records review, observation and interviews with relevant parties. The allegation indicates that Facility has mold. During the investigation, LPAs Brown and Wolcott did not find evidence to corroborate the allegation. Oservations and interviews with Staffs #1 to #7 and Residents #1 to #10 indicated that they did not observe mold at the facility. During the facility visit on 08/03/2023. LPA Brown did not ***Continuation in LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20230731093552
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
, CA 92507
FACILITY NAME: HERITAGE COURT ASSISTED LIVING
FACILITY NUMBER: 366413073
VISIT DATE: 11/06/2023
NARRATIVE
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observe mold in Resident #1 (R1) room and during the facility visit on 11/06/2023, LPAs Brown and Woldcott toured the facility and did not observe mold on residents rooms.

Based on the evidence, the allegation that Facility has mold is UNSUBSTANTIATED. A finding that the complaint is 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, therefore the allegation is unsubstantiated at this time.


An exit interview was conducted where this report, LIC9099 was discussed and provided to Assistant Administrator Lauren Calvani
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 56-AS-20230731093552
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
, CA 92507

FACILITY NAME: HERITAGE COURT ASSISTED LIVING
FACILITY NUMBER: 366413073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety... This requirement was not met as evidenced by:
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Licensee stated to add one (1) Housekeeping staff per day to make sure all residents rooms are clean everyday and will submit proof of updated Housekeeping Staff Schedule to LPA Brown at POC due date.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not maintaining the facility clean and sanitary and not having housekeeping staff clean residents bedrooms daily which pose potential health, safety and personal rights risks to residents in care.
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Type B
11/20/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety... This requirement was not met as evidenced by:
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Licensee stated to repair the bathroom near the Dining Room, broken closet door in Room #117 and submit proof to LPA Brown at POC due date.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not having the facility bathroom near the dining room in good repair for 3 to 4 months now and the closet door in Room #117 in disrepair wich pose potential 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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6