HERITAGE HILLS

Official classification

Type A

Official code

87468.1(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights ... (a)…residents… shall have... the following personal rights: (4) To care, supervision, and services that meet their... needs and are delivered by staff that are sufficient in...qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and records review the licensee did not comply with the section above in that R1 was not provided care and supervision, which posed an immediate health, safety, and personal rights risk to one (1) out of sixty-four (64) residents in care.

Official plan of correction

Licensee agrees to schedule an in-service training on the topics of care and supervision and send proof of scheduling to the Department by 6/6/2025. Licensee agrees to send sign-in sheet and training topics to the Department by 7/4/2025.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities (a) Residents … shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interviews and records review the licensee did not comply with the section above in that one (1) out of (64) residents bedrails were in disrepair, which posed a potential health, safety, and personal rights risk.

Official plan of correction

Licensee agrees to schedule an in-service training on the topic of personal rights and send sign-in sheet and training topics to the Department by POC date of 7/4/2025.

Deadline recorded: Jul 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence (b)... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. Based on observation, interview, and recordreview, the licensee did not ensure that The facility was free of odors from intcontinence care, which posed a potential Health, Safety, and Personal rights risks to 1 of 78 persons in care.

Official plan of correction

Licensee will ensure room of resident is clear of odors by 07/20/26. A representative of CCLD Offices will conduct a facility visit to ensure POC is cleared.

Deadline recorded: Jul 15, 2026. 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

Basic Services 87464(f) Basic services... include: (1) Care and supervision as defined in Section 87101(c)(3) Health and Safety Code (c) " Care and supervision " means the facility assumes responsibility for... ongoing assistance with activities of daily living... " Based on observation, interview, and record review, the facility did not ensure that all resident signal alerts were answered in a timely manner, which posed a potential Health, Safety, and Personal rights risks to 1 of 76 persons in care.

Official plan of correction

Executive Director will implement inservice training to staff about signal system requirements and proper staff equipment care. Facility will send CCLD offices proof of training by 02/27/26

Deadline recorded: Feb 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

Basic Services 87464(f) Basic services... include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... Based on observation, interview, and record review, the facility did not ensure that all resident toileting needs were met, which posed a potential Health, Safety, and Personal rights risks to 1 of 76 persons in care.

Official plan of correction

Executive Director will implement incontinence care recording system to ensure staff are meeting resident needs. Facility will do inservice training and send CCLD offices proof of training by 02/27/26

Deadline recorded: Feb 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above in that several items including dressings, sauces, and canned products were expired and in refridgerator/pantry which poses a potential health, safety or personal rights risk to 76 of 76 persons in care.

Official plan of correction

POC Due Date: 11/21/2025 Plan of Correction Purchasing more tools and labels to help with visibility. Inservice of proper labeling techniques and food storage safety. Evidence of these purchases, intended use, and signatures of the training shall be submitted to CCLD Offices 11/21/2025

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above in that vegetables (onions, lettuce, potatoes) and fruits (lemons, tomatoes) were left uncovered and had no labeled dates which poses a potential health, safety or personal rights risk to 76 of 76 persons in care.

Official plan of correction

POC Due Date: 11/21/2025 Plan of Correction Purchasing more tools and labels to help with visibility. Inservice of proper labeling techniques and food storage safety. Evidence of these purchases, intended use, and signatures of the training shall be submitted to CCLD Offices 11/21/2025

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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... This was not met as evidenced by: Based on interviews and records review, R1 was able to ingest a chemical that was left unlocked/unsupervised by facility staff which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee to provide an in-service training for staff regarding supervision of residents. Licensee to submit by POC Deadline.

Deadline recorded: Oct 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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... 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.

Official plan of correction

Licensee to provide an in-service training for staff regarding supervision of residents. Licensee to submit by POC Deadline.

Deadline recorded: Oct 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(c)(3)

Regulation authority

CCR

What the official deficiency says

Reappraisals (c) If the licensee observes or is made aware of behavioral expression, as defined in Section 87101, that has caused or may cause harm to the resident or others, the licensee shall document all of the following in the resident’s reappraisal: (3) Interventions to be implemented to minimize the risks to the health and safety of the resident or others associated with the resident's behavioral expression. The licensee shall use the least restrictive intervention to manage the behavioral expression based on the individual needs of the resident. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not ensure that R2 received a reappraisal after a significant change in condition and behavioral expression to minimize risks to other residents in care. This posed an immediate safety risk to 70 of 70 residents in care.

Official plan of correction

Licensee agrees to schedule an in-service training on the topics of Reappraisals and recognizing residents change in behaviors 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.

Deadline recorded: Feb 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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.

Deadline recorded: Feb 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.312(e)

Regulation authority

HSC

What the official deficiency says

1569.312 Basic services requirements: " (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. " This requirement was not met as evidence by: Based on interview, the licensee did not comply with the section cited above in one (1) out of sixety-nine (69) residents which posed a potential health and safety risk to persons in care.

Official plan of correction

Licensee agrees to conduct a training for their current direct care staff and activities staff on the topic of Monitoring Activities & Supervision. Licensee agrees to send training agenda and sign in sheet to CCL by POC date of 01/29/2024.

Deadline recorded: Jan 29, 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

87468.1(a) Residents in all residential care facilities for the elderly 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 interviews, Licensee did not accord 1 of 70 residents (R1) dignity in their personal relationships with staff. This posed a potential personal rights risk to persons in care.

Official plan of correction

Licensee terminated staff member S2, effective 6/22/23. Licensee agreed to coordinate retraining of all staff on 87468.1 Personal Rights, and to submit the training sign-in sheet(s) to LPA by the POC due date, as proof.

Deadline recorded: Nov 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(2)(3)

Regulation authority

CCR

What the official deficiency says

87625(b)... " Licensee shall be responsible for ensuring (2)...that incontinent residents are checked... when they are known to be incontinent...(3) incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met, evidenced by: Based on interviews and observations, Licensee did not: check residents when known to be incontinent, ensure residents' were clean/dry, or ensure the facility remained free of odors of incontinence. This posed a potential health risk to 70 of 70 residents in care.

Official plan of correction

Licensee agreed to coordinate retraining of all staff on 87625 Managed Incontinence, and to submit the training sign-in sheet(s) to LPA by the POC due date, as proof.

Deadline recorded: Nov 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General: “(a) Facility personnel shall at all times be…competent to provide the services necessary to meet resident needs.” This requirement was not met, as evidenced by: Based on interviews, within the context of effective searching following a delayed-egress door alarm, the licensee did not ensure facility personnel were competent to provide the services necessary to meet the needs of 1 of 71 residents (R1), which posed a potential safety risk to persons in care.

Official plan of correction

Licensee agreed to codify in writing new procedures/expectations regarding how staff should respond after discovering that a delayed-egress door has alarmed and unlocked. The actions will include but are not limited to: 1) Finding the source/person who opened the door, and 2) Performing a head count of the residents to ensure all are accounted for. Licensee agreed to train its staff on these procedures, and E-mail the training sign-in sheet to LPA by the POC due date.

Deadline recorded: Aug 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.317

Regulation authority

HSC

What the official deficiency says

1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan…” This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff did not develop an absentee notification plan for 71 of 71 residents (R1 through R71), which posed a potential safety risk to persons in care.

Official plan of correction

During today’s visit, Licensee wrote an Absentee Notification Plan and provided a copy of it to LPA. Licensee agreed to print and add this document as an addendum the written record of care for each of its current residents. Licensee agreed to train all its current staff on this document, and to E-mail the training sign-in sheet to LPA by the POC due date.

Deadline recorded: Aug 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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 was not as evidence by: Based on interviews and observations, the Licensee did not ensure the facility was clean and sanitary, whcih posed a potential health, safety, and personal rights risk to 69 of 69 persons in care.

Official plan of correction

Business Office Director agreed for facility to provide in service training to all staff regarding cleaning procedures, by 6/16/23. Business Office Director agreed to submit proof to the department of staff who attended the training, subjects discussed and date, by 6/16/23.

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

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidence by: Based on interviews, the Licensee did not ensure staff assisted residents with activities of daily living such as dressing, which posed a potential health, safety and personal rights risk to 69 of 69 person in care.

Official plan of correction

Business Office Director agreed for facility to provide in service training to all staff regarding activities of daily living, by 6/16/23. Business Office Director agreed to submit proof to the department of staff who attended the training, subjects discussed and date, by 6/16/23.

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

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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. 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 was not met as evidence by: Based on interviews and review of records, the Licensee did not ensure staff were competent to provide services necessary, which posed a potential health, safety, and personal rights risk to 69 of 69 persons in care.

Official plan of correction

Business Office Director agreed for facility to provide in service training to all staff regarding Personnel Requirements, by 6/16/23. Business Office Director agreed to submit proof to the department of staff who attended the training, subjects discussed and date, by 6/16/23.

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

Official classification

Type B

Official code

87211(a)(a)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a)(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 has not been met as evidenced by: Based on interviews and records review, the Licensee did not submit an incident report to the Department regarding R1's fall. This poses an potential safety risk to 68 of 68 residents in care.

Official plan of correction

Executive Director stated they will review regulation 87211 and submit a letter to the Department stating understanding of reporting requirements and will submit incident reports for all incidents, regardless of injury by POC due date.

Deadline recorded: May 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.699(a)(7)(A)

Regulation authority

HSC

What the official deficiency says

1569.699 Exit doors; egress-control devices of time-delay type; fences: (a)(7)(A) A sign shall be provided on the door located above and within 12 inches (305mm) of the panic bar or other door-latching hardware…” This requirement was not met, as evidenced by: Based on LPA observation, licensee did not place the required sign within 12 inches of the panic bar or other door-latching hardware for 2 of 6 delayed-egress exit doors, which posed a potential safety risk to persons in care.

Official plan of correction

Licensee agreed to add an additional signage (meeting the requirements of California Health and Safety Code Section 1569.699(a)(7)) to its “1st Floor South” and “1st Floor North” delayed-egress doors, such that they are positioned within 12 inches from the panic bar or door-latching hardware. Licensee agreed to E-mail LPA photos of such by the POC due date.

Deadline recorded: May 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)(1)

Regulation authority

CCR

What the official deficiency says

The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1)...Thirty (30) days written notice to the resident is required...Nonpayment of the rate for basic services within ten days of the due date.This requirement has not been met as evidenced by: Based on interviews and records review, Thirty (30) days written notice to the resident was not issued for Nonpayment of the rate for basic services...for 1 in 1 of 64 persons in care [R1] which posed an immediate safety and personal rights risk to persons in care.

Official plan of correction

Per ED Stefanie Ancheta they will comply by issuing a 30 day notice for non-payment. Ed will conduct staff inservice with department heads. Will send LPA roster of staff that attended by 11/30/22.

Deadline recorded: Nov 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)(c)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f)(1)(c) Basic Services. Care and supervision as defined in section 87101(c)(3) and Health and Safety Code section 1569.2(c). “Care and Supervision” means the facility assumes responsibility for…on going 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 record review and interviews, the licensee did not provide basic services for 1 out of 72 residents, by not providing the required supervision which poses an immediate health and safety risk to residents in care.

Official plan of correction

Executive Director Stefanie Ancheta was pro active in providing In- Service training to staff on 9/7/2022 regarding the servery doors to remain closed at all times. Place service order to adjust the hydraulic spring device on the servery door by the POC due date of 9/24/2022.

Deadline recorded: Sep 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2

Regulation authority

CCR

What the official deficiency says

Personal Rights of All Residents--Residents have the right to reasonable privacy in accommodations. This requirement is not met as evidenced by: observation of resident doors are being kept locked during day, preventing reasonable access and privacy. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for all residents which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2019 Plan of Correction Licensee stated they will conduct staff training on personal rights including alternative strategies to address wandering and related concerns. Will submit copy of completed training materials, agenda, sign ins by POC date.

Official classification

Type B

Official code

87555(26)

Regulation authority

CCR

What the official deficiency says

Food Service Requirements--Seven day supply of non-perishable and two day supply of perishable foods shall be kept on the premises. This requirement is not met as evidenced by: observation of inadequate perishable food items on hand. Pantry was sparse, with empty shelves and very few fresh items noted that would meet planned menu options as per weekly menu lists. Deficient Practice Statement Based on observation the licensee did not comply with the section cited above in which poses a potential safety risk to all persons in care.

Official plan of correction

POC Due Date: 12/06/2019 Plan of Correction Licensee will review current food ordering and delivery systems and procedures to ensure adequate fresh food supplies are maintained on site. Will submit copy of food ordering and delivery procedures by POC date as verification.