HERITAGE POINTE

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

(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... R1 left the facility unattended on July 27, 2026, R1 is not allowed to leave the facility unassisted, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee already conducted an in-service training for all staff members on CCR 87464 and will provide a copy of the sign-in sheet for all staff in attendance. Licensee agrees to provide an outline of topics covered in the in-service, including the duration of the in-service training and a list of all participants. Proof of correction to be sent to the LPA.

Deadline recorded: Aug 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(b)

Regulation authority

CCR

What the official deficiency says

Per CCR 87463(b), “the reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition”. This requirement is not met as evidenced by: Based on records reviewed, R1 was never assessed to be a fall risk in spite of multiple occurrences of falls between May 2023 and January 2024, at least one of which resulted in an injury. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee agrees to review section cited and submit proof before the plan of corrections due date.

Deadline recorded: Apr 1, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Per CCR, “Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency (…) within seven days of the occurrence of any of the events specified in (A) through (D) below. (D) Any incident which threatens the welfare, safety or health of any resident (…)” This requirement was not met as evidenced by: Multiple fall incidents including instances that resulted in injury and/or hospitalization were not reported to the Department. This constitutes a potential

Official plan of correction

Licensee agrees to review reporting requirements and submit proof before the plan of corrections due date. risk to the health, safety and personal rights of individuals in care.

Deadline recorded: Apr 1, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that Staff #11 (S11), Staff #12 (S12), Staff #13 (S13). Staff #14 (S14), Staff #15 (S15), and Staff #16 (S16), were not criminal background cleared or associated to the facility.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction The ED stated that she will ensure that all six staff complete a live scan and obtain a criminal record clearance prior to their continued employment. The ED agreed to provide LPA a plan on when it will be completed for the six staff via email or fax by POC date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the facility did not have Resident #11 (R11) Quetiapine Fumarate 25 MG medication present at the facility, despite R11 having an active order for the medication. LPA observed the facility did not have Resident #12 (R12) Fluticasone 50 MG medication, Milk of Magnesium, or Polyethylene, present at the facility, despite R12 having active orders.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction The ED stated that an in service training will all staff who manage medication will be completed. The ED agreed to provide LPA proof of the in service training via email or fax by POC date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that one delayed egress door in the memory care portion was non-operational at time of visit.

Official plan of correction

POC Due Date: 03/27/2026 Plan of Correction The ED stated that they will repair the delayed egress door to ensure it is operational. LPA to conduct a subsequent visit to ensure the repair has been made.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that Staff #1 (S1) did not have any annual training on file for the year of 2025.

Official plan of correction

POC Due Date: 03/27/2026 Plan of Correction The ED stated that they will have S1 complete the required twenty hours of annual training for the year of 2025. The ED agreed to provide proof of training for S1 to LPA via email or fax by POC date.

Official classification

Type B

Official code

87555(b)(15)

Regulation authority

CCR

What the official deficiency says

(15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During a tour of the kitchen, LPA observed one staff preparing food without a hairnet. The staff advised LPA that they did not have any hairnets and that they had to be ordered.

Official plan of correction

POC Due Date: 03/27/2026 Plan of Correction The ED stated that hairnets will be ordered for the kitchen and an in service training will be conducted with kitchen staff regarding personal hygiene. The ED agreed to provide LPA proof of training via email or fax by POC date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed the Reappraisals on file for Resident #2 (R2), Resident #6 (R6), and Resident #7 (R7) were outdated and need to be updated.

Official plan of correction

POC Due Date: 03/27/2026 Plan of Correction The ED stated that Reappraisals will be completed for the three residents. The ED agreed to provide LPA the Reappraisals for the three residents via email or fax by POC date.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

Per CCR87477 Observation of the resident: " The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. " This requirement is not met as evidenced by the fact that R1's four broken teeth went unnoticed until they were diagnosed during a dentist visit organized by R1's responsible party. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Once the four teeth were extracted, R1's assessment was updated to reflect the need for a mechanical soft diet. Defiency cleared during the present visit.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87618(b)(1)

Regulation authority

CCR

What the official deficiency says

Per CCR Section 87618(b)(1) on Oxygen Administration: " the licensee shall be responsible for the following: Monitoring of the resident's ongoing ability to operate the equipment in accordance with the physician's orders " . This requirement was not met as evidenced by: Based on interviews and record reviews, facility staff did not monitor R1's ability to operate their oxygen equipment and failed to provide timely assistance. This constitutes a potential risk to the health, safety and personal rights of residents in care,

Official plan of correction

Licensee to audit residents using oxygen equipment to ensure their ability to operate in accordance to physician orders. Proof of review to be submitted before the plan of corrections due date.

Deadline recorded: Aug 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Per CCR 878464(f)(1) on Basic Services: " 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 is not met as evidenced by: Based on records reviewed and interviews conducted, instances of excessive response times were recorded for resident R1 over the reviewed period of January 2022.This constitutes a potential risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee received a similar citation for more recent instances of the same allegations. Current corrections will be reviewed in order to clear this additional deficiency based on older circumstances.

Deadline recorded: Jul 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

878464(f)(1)

Regulation authority

CCR

What the official deficiency says

Per CCR 878464(f)(1) on Basic Services: " 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 is not met as evidenced by: Based on records reviewed and interviews conducted, multiple instances of excessive response times were recorded.This constitutes a potential risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee will utilize the newly hired Wellness Director to keep track and audit pendant pushes regularly, conduct bi-monthly in-service training and identify root causes of excessive wait times. Documentation of the corrections to be provided to LPA before the plan of corrections due date. CIVIL PENALTY FOR REPEAT VIOLATION ASSESSED

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Per CCR (a) 87468.1(a)(1) defining Personal Rights: " Residents in all RCFE shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons " . This requirement was not met as evidenced by: Based on staff and resident interviews conducted, staff member S1 was responsible of inappropriate behavior towards multiple residents. This constitutes a potential risk to the health, safety and personal rights of residents in care.

Official plan of correction

Staff member S1 was terminated with cause by licensee on March 11, 2025 as confirmed by interviews and a review of staff files. No other staff evidenced to have interacted inappropriately with residents during the investigation. Deficiency cleared.

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

878464(f)(1)

Regulation authority

CCR

What the official deficiency says

Per CCR 878464(f)(1) on Basic Services: " 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 is not met as evidenced by: Based on records reviewed and interviews conducted, multiple instances of excessive response times were recorded.This constitutes a potential risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee will utilize the newly hired Wellness Director to keep track and audit pendant pushes regularly, conduct bi-monthly in-service training and identify root causes of excessive wait times. Documentation of the corrections to be provided to LPA before the plan of corrections due date.

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.2(c)

Regulation authority

HSC

What the official deficiency says

" Care and supervision " means the facility assumes responsibility for... ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety or welfare would be endangered. This requirement is not met as evidenced by: Based on staff interviews and records review, the licensee did not comply with the section cited above as residents' medications are not being dispensed as prescribed, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

ED stated staff training on medication management will be conducted and a copy provided to LPA with proof via email by POC date.

Deadline recorded: Apr 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as four of nine resident MARs were observed to be incomplete, which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

ED stated residents' MARs will be updated to reflect correct information regarding medication administration and copy provided to LPA via email by POC date.

Deadline recorded: Apr 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as an incident report was not submitted within seven days following a medication error which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

ED stated they will provide LPA with a written plan of action to ensure compliance with regulation via email by POC date.

Deadline recorded: Apr 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(6)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by: Deficient Practice Statement Based on a review of a sample of resident records, the licensee did not comply with the section cited above as two physician reports reviewed in a total of 10 had been conducted more than a year prior to the visit. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2024 Plan of Correction Licensee will obtain updated medical assessments for the two residents in question and provide LPA with proof of update by the plan of corrections due date of April 28, 2024.

Official classification

Type B

Official code

87507(g)(3)(B)(2)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87507(g)(3)(B)(2) states that: " A separate charge (...) may be assessed only if that charge is included in and authorized by the admission agreement. " In the absence of the agreement and due to the COVID waivers in place at the time, the separate (...) charges for tray services should not have been assessed as observed on billing documents. This constitute a potential risk for the health, safety and personal rights of residents in care.

Official plan of correction

Licensee will re-initiate the dialogue with R1's family to resolve any potential excess paid. Proof of the discussion will be provided to LPA by the Plan of Corrections due date.

Deadline recorded: Dec 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87464(f) on Basic Services states that: “Basic services shall at a minimum include care and supervision [meaning] (...) responsibility for (...) ongoing assistance with ADLs without which the resident’s physical health(...) would be endangered. Assistance includes (...) taking medication” This requirement is not met as evidenced by records reviewed at the facility and interviews conducted with staff confirmed that resident R1 was left out of Medication Management for after being assessed to require ongoing assistance with medication.

Official plan of correction

Facility staff is to audit the medical assessments for all residents not currently on Medication Management to verify that no other residents should have been transitioned at this time, and, if applicable, transition the residents in question before the plan of corrections due date.

Deadline recorded: Nov 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87705 states that: " (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, (...) and toxic substances (...). " This requirement is not met as evidenced by: Based on observations and interviews conducted during the initial inspection, substances falling under this regulation were found in two Memory Care bathrooms. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.

Official plan of correction

During the initial visit on March 28, 2023, staff confirmed that the medication in question should have been secured in the medication cart and proceeded to relocate it. Upon follow-up visit on June 2, 2023, the correction was confirmed to have been (...) implemented and was still in place. Therefore the plan of corrections is considered to be effective and the deficiency was cleared during the visit.

Deadline recorded: Jun 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87311

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations 87311 Telephones states that: " All facilities shall have telephone service on the premises. " This requirement was not met as evidenced by: Based on a majority of interviews conducted, telephone outages have been a common occurrence throughout the first semester of (...) the calendar year 2022 after a new phone system was installed by the facility. This posed a potential risk to the health, safety and personal rights of the residents in care.

Official plan of correction

While occasional maintenance request services are still occasionally submitted to the facility administrator, systems are now operational and most if not all issues are due to user errors rather than systemic outages. The deficiency is therefore cleared during the visit.

Deadline recorded: Apr 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87464(f) on Basic Services states that: “Basic services shall at a minimum include care and supervision [meaning] the facility assumes responsibility for (...) ongoing assistance with activities of daily living without which the resident’s physical health(...) would be endangered. Assistance includes (...) taking medication” This requirement is not met as evidenced by records reviewed at the facility and interviews conducted with staff confirmed that resident R1 was left out of Medication Management for 16 months after being assessed to require assistance with self-administration.

Official plan of correction

Facility staff is to audit the medical assessments for all residents not currently on Medication Management to verify that no other residents should have been transitioned at this time, and, if applicable, transition the residents in question before the plan of corrections due date.

Deadline recorded: Feb 18, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87465(a)(4) on Incidental Medical and Dental Care states that: “The licensee shall assist residents with self-administered medications as needed.” This requirement is not met as evidenced by the delay observed in the implementation of the resident’s transition into Medication Management.

Official plan of correction

Facility staff is to audit the medical assessments for all residents not currently on Medication Management to verify that no other residents should have been transitioned at this time, and, if applicable, transition the residents in question before the plan of corrections due date.

Deadline recorded: Feb 18, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468(a)

Regulation authority

CCR

What the official deficiency says

Personal Rights- (a) Residents in residential care facilities for the elderly shall have personal rights...those listed in Sections 87468.1,Personal Rights... and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. CONTINUED BELOW This requirement was not met as evidenced by:Resident's call light alarm in Room 6A was not nswered in a timely manner. Based on LPAobservation and interviews which were conducted, resident call light alarms are not answered in a timelymanner. This poses a potential health, CONTINUED ...

Official plan of correction

The facility stated a training will be conducted with all caregivers to outline their responsibilities in responding to resident's call lights in a timely manner and the importance of utilizing their radio and Beepers to allow notification of the call. Proof of training will be provided to LPA by December 17,2021. CONTINUED...safety and personal rights risk to residents in care.

Deadline recorded: Dec 9, 2021. A deadline is not proof that correction was completed.