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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603778
Report Date: 09/29/2025
Date Signed: 09/29/2025 03:11:48 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
08/06/2024 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20240806155419
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: DATE:
09/29/2025
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Executive Director Mike McCoyTIME COMPLETED:
11:51 AM
ALLEGATION(S):
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Lack of supervision resulting in resident sustaining serious bodiily injuries from a physical altercation with another resident
INVESTIGATION FINDINGS:
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On 9/29/2025, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Executive Director Mike McCoy and explained the purpose of the call.

Regarding the allegation of Lack of supervision resulting in resident sustaining serious bodily injuries from a physical altercation with another resident, Reporting Party (RP) reported an unwitnessed fight occurred in the facility. A staff checked on a resident (R1) at 5am and found R1 lying on the ground in blood.

Staff members were interviewed during the course of the investigation.

On 08/05/24, at about 0530 hours, S1 found R1 on the floor in R1s shared room also occupied by R2. S1 assessed injuries on R1 and called for assistance from S2 and after assessing the resident, S2 called 911, R1 had bleeding from the back of his/her head and face.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
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 3
Control Number 08-AS-20240806155419
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: 09/29/2025
NARRATIVE
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***This is an amended report ***
Responding Officer (RO), interviewed staff to determine how the incident occurred. S3 had informed RO that R2 had physically assaulted another resident in the past with a footrest from a wheelchair. S3 also added that when new residents move in the staff monitor them for 48 hours checking on them and making sure they are adjusting to their environment and staff conduct status checks every hour. During the investigation, RO was informed by S4 that he/she had just recently been hired on and was in training and onboarding and did not have the opportunity to review residents’ files or conduct follow-up assessments for residents like R2 regarding change of condition. It is unclear what action was taken after R2 had assaulted the previous resident R3. R2 continued to reside in the room without a roommate for over a month until R1 was assigned to that room. S4 informed RO that S4 did not check the diagnoses or care plans of the residents to see if the residents were compatible before moving them in together. It was reported by staff that R2 preferred to be alone and by himself/herself, R2 was not sociable with other residents and only engaged with the staff. R2 had panic attack disorder and anxiety, a mental health condition that should have been addressed to determine if R2 was suitable for the facility. S4 admitted to not reviewing service plans for residents and did not have the opportunity to address any change of conditions with the residents due to onboarding and trying to manage S4s responsibilities. S4 also mentioned that the facility was using outside agencies for caregivers and attempting to hire more staff. After the former RSD left some of the caregivers also left leaving them understaffed.

Based on records review, R2 has had experiences of panic disorder which happens with sudden attacks of intense anxiety that occur without any specific trigger or situation. There is no record of reappraisal when the first incident happened with R3.

Therefore, in the matter of Neglect/Lack of Care and Supervision resulting in R1 being assaulted by R2, the findings are substantiated.

At the time of the complaint inspection on 8/8/2024, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49.

Based on observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D.

Report is reviewed and a copy of the report and Appeal Rights is provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240806155419
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: 09/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... 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...
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Licensee to provide an in-service training for
staff regarding supervision of residents.
Licensee to submit by POC Deadline.
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This was not met as evidenced by:
Based on interviews and records review, R1 was assaulted by R2 due to staff lack of supervision and constant checks for R2 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: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2025
LIC9099 (FAS) - (06/04)
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