<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603778
Report Date: 02/24/2025
Date Signed: 02/24/2025 04:39:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2024 and conducted by Evaluator Hannah Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20240725111316
FACILITY NAME:HERITAGE HILLSFACILITY NUMBER:
374603778
ADMINISTRATOR:STEFANIE ANCHETAFACILITY TYPE:
740
ADDRESS:2108 EL CAMINO REALTELEPHONE:
(760) 206-7930
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:78CENSUS: 64DATE:
02/24/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Executive Director Mike McCoyTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of supervision resulting in resident sustaining multiple fractures from a physical altercation with another resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Hannah Rodgers and Sabel Martinez conducted an unannounced subsequent visit to deliver findings regarding the above allegation. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Mike McCoy.

The Department's investigation consisted of record review, interviews with facility staff, residents, and outside sources including medical professionals and family members. It was alleged that lack of supervision resulted in resident #1 (R1) sustaining multiple fractures from a physical altercation with resident #2 (R2). It was specifically reported that on June 10, 2024, R1 and R2 were in a physical altercation that resulted in R1 sustaining multiple rib fractures.

[Continued on LIC9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
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 4
Control Number 08-AS-20240725111316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HERITAGE HILLS
FACILITY NUMBER: 374603778
VISIT DATE: 02/24/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The Department received video footage that corroborated the incident that occurred on, June 10, 2024, at 8:12 AM. The video footage revealed R1 and R2 in a physical altercation. Video footage depicted R2 punching R1 several times in the abdominal area and subsequently throwing R1 to the floor. Staff were summoned by a resident and assessed R1 and R2. A 911 call was initiated at 8:24 AM, and R1 was transported to a local hospital. Law enforcement was contacted and R2 was removed from the facility on a 5150-hold due to danger to others.

The Department has investigated the allegation that Neglect/Lack of Supervision resulted in serious bodily injuries and has found that based upon record review, video recordings, and interviews, the licensee did not conduct a reappraisal of R2 to determine if the facility was appropriate placement after R2 exhibited multiple aggressive behaviors towards staff and residents. Therefore, the preponderance of the evidence standard has been met and the allegation is deemed substantiated.


This deficiency is noted on the attached 9099-D and is cited in accordance with the California Code of Regulations, Title 22. An immediate $500 civil penalty was assessed, and a plan of correction was jointly formulated with Executive Director Mike McCoy. Per Health and Safety Code Section 1569.49, an additional civil penalty is under review by the Program Administrator of the Community Care Licensing Division.

An exit interview was conducted and a copy of this report, LIC 421IM, LIC 811, along with Licensee/Appeal Rights (LIC 9058 03/22) were provided to Mike McCoy at the conclusion of the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20240725111316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HERITAGE HILLS
FACILITY NUMBER: 374603778
VISIT DATE: 02/24/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Review of R1’s physicians report, dated July 19, 2023, revealed R1 has a diagnosis of dementia without aggressive behaviors. According to R1’s pre-appraisal, dated July 28, 2023, R1 uses a walker to ambulate through the facility. Review of R2’s physician’s report, dated May 14, 2024, revealed R2 had a diagnosis of Alzheimer’s Dementia, and had occasional aggressive behavior and confusion. Review of R2’s facility progress notes revealed multiple occurrences of aggressive behavior towards staff and residents after admission.

Review of R2’s progress notes revealed on May 25, 2024, the day following their admission to the facility, R2 was in a physical altercation with Staff #5 (S5), resulting in R2 pushing staff up against the wall by the shoulders with full force. R2 then entered a resident’s room and began pushing the resident. Staff redirected R2 away from the resident. On May 28, 2024, R2 was observed going in and out of a resident’s room and pushing them out of their way. On June 3, 2024, while staff were assisting a resident, R2 entered R3’s room and pushed Staff #13 (S13). When S13 tried to redirect R2, R2 became agitated and attempted to tackle S13. On June 6, 2024, R2 entered R3’s room and became aggressive with R3, but Staff #8 (S8) was able to redirect R2. During the incident, R2 squeezed S8’s hands.

On June 9, 2024, R2 displayed aggressive behavior by walking up to staff and hitting their fist into their hands. Record review revealed that after multiple occurrences of aggression displayed by R2, a reappraisal was not conducted to reassess R2’s needs or compatibility with other residents. Facility progress notes and medical records revealed that R2 was prescribed as needed medication for agitation and anxiety.

Interview with Staff # 7 (S7) revealed a request was sent to R2’s physician for medication adjustments but denied receiving an updated prescription. Review of medical records revealed that the request was received on May 28, 2024, and medication adjustments were made by the physician, but delays occurred with an outside pharmacist.

Interviews with 12 staff members were conducted (S1-S12). S1 – S3 reported that R1 and R2 were present in the Sea Breeze dining room when R2 assaulted R1. Interviews with S9 revealed that on June 8, 2024, R1 and R2 had previously been in a verbal altercation where R2 made verbal threats against R1, and staff had to separate them for their safety. Interviews with S4 and S5 corroborated the physical altercation that occurred on June 6, 2024, where R2 entered a resident's room and became aggressive with staff. The Department attempted to interview R1 and R2 but was unable to qualify them due to their cognitive state.

[Continued on LIC9099-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20240725111316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HERITAGE HILLS
FACILITY NUMBER: 374603778
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2025
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
 87464 Basic Services
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to schedule an in-service training on the topics of care and supervision and send proof of scheduling to the Department by 2/25/25. Licensee agrees to send sign-in sheet and training topics to the Department by 3/17/2025.
8
9
10
11
12
13
14
Based on record review and interviews, the licensee did not ensure that R1 was provided care and supervision, which posed an immediate health, safety, and personal rights risk to 1 (R1) of 64 residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4