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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366413073
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:38:00 PM

Document Has Been Signed on 11/06/2023 03:38 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: 51DATE:
11/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Assistant Administrator Lauren CalvaniTIME COMPLETED:
03:45 PM
NARRATIVE
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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 initiate a Case Management Visit. LPAs Brown and Wolcott explained the purpose of the visit. The investigation consisted of interviews and a review of pertinent documentation.

Per review of R1's Physician Report (LIC602), LPAs Brown and Wolcott observed that the facility failed to complete the required annual medical assessment, reappraisal and reassessment done for R1's dementia care needs. LPA Brown informed Assistant Administrator Lauren Calvani that deficiency will be issued as this pose potential health, safety and personal rights risk to residents in care.

An exit interview was conducted where this report LIC809, 809D 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
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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Document Has Been Signed on 11/06/2023 03:38 PM - It Cannot Be Edited


Created By: Melody Brown On 11/06/2023 at 02:36 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: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2023
Section Cited
CCR
87705(5)

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87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of...This requirement is not met as evidenced by:

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Licensee stated to complete R1's updated LIC602 and submit proof to LPA Brown at POC due date.
The Licensee stated to train all staff on CCR 87705(5) and submit proof of Training Log to LPA Brown at POC due date.
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Based on interviews & records review, the Licensee did not comply with the section cited above by failing to complete the required annual medical assessment, reappraisal and reassessment done for R1's dementia care needs which pose potential health, safety and personal rights risks to resident 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: 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


LIC809 (FAS) - (06/04)
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