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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366413073
Report Date: 01/29/2024
Date Signed: 05/01/2024 11:02:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/31/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231031091352
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: 46DATE:
01/29/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Leilin MoseleyTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not properly address resident's multiple falls at facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Wellness Director Leilin Moseley and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff did not properly address resident's multiple falls that occured at the facility. During interviews and review of records it was revealed that Resident #1 had sustained an unwitnessed fall on 7/1/2023, a fall in which staff failed to report. During review of records LPA observed that facility did not have a mitigation plan in place to help minimize Resident #1 with continous falls. During resident interviews residents reported to LPA that Resident #1 on several occasions has fallen and in some occasions was assisted by caregivers. Based on the evidence gathered during the investigation, the above allegation is Substantiated. Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Personnel Requirements – General 87411 (a), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
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 5
Control Number 56-AS-20231031091352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HERITAGE COURT ASSISTED LIVING
FACILITY NUMBER: 366413073
VISIT DATE: 01/29/2024
NARRATIVE
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An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights to Facility Wellness Director Leilin Moseley at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20231031091352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HERITAGE COURT ASSISTED LIVING
FACILITY NUMBER: 366413073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
87411(a)
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Personnel Requirements – General 87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidence by:
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Administrator has agreed to go over Personnel Requirements – General regulation and provide training to all caring staff regarding Personnel Requirements when providing care. Administrator will provide proof of signed documentation by all staff support by POC date 5/31/2024. Administrator will email documentation to LPA Guerrero.
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Based on interviews and record review, facility staff did not follow proper requirements when Resident #1 sustained falls, which poses an immediate Health, Safety, or Personal Rights risk to persons 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: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/31/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231031091352

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: 46DATE:
01/29/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Leilin MoseleyTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff does not safeguard resident’s personal belongings.
Staff mismanaged resident’s medication.
Staff does not provide residents with food of good quality.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Wellness Director Leilin Moseley and explained the purpose of the visit. The investigation consisted of interviews and review of records.

Second allegation, Staff does not safeguard resident’s personal belongings. During interviews and review of records it was revealed that the facility has a theft program in place and documents all residents’ valuables onto an inventory check list pertaining to each resident. In addition, during residents interviews all residents reported that the facility provides all residents with the storage space for residents to store their own personal belongings. During interviews with residents all reported not having issues with personal belongings being stolen or gone missing.

Third allegation, Staff mismanaged resident’s medication. During interviews and record review LPA reviewed Resident #1 MAR record and observed medication to be administered correctly. During interviews with residents all reported not having issues with medication given incorrectly by staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
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 5
Control Number 56-AS-20231031091352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HERITAGE COURT ASSISTED LIVING
FACILITY NUMBER: 366413073
VISIT DATE: 01/29/2024
NARRATIVE
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Fourth allegation, Staff does not provide residents with food of good quality. LPA conducted a walked through of the facilities kitchen, pantry, and refrigerators, and freezers, LPA observed adequate amount of food in the refrigerators, pantries, and freezers. LPA checked temperature logs and observed refrigerators and freezers to be at the required temperatures based on regulation. LPA observed canned goods, perishable and non-perishable, fruit, and vegetables to be in good standing and not expired. Interviews and observations indicated that facility has a menu available, along with alternatives based on resident’s request. LPA retrieved a copy of facilities weekly menu. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.

Unsubstantiated; meaning that 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.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Wellness Director at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5