Heritage Hills

LPMII RA, Donna Teutschel, conducted a telephone interview with Administrator, Mike McCoy. The investigation did not produce definitive supporting evidence or supporting witness statements to substantiate an allegation of neglect or lack of supervision on the part of Heritage Hills staff that caused or contributed to resident (R1) being assaulted by resident (R2) which resulted in injuries to R1. Although it was established that R2 had become more agitated and agressive he had not been physically violent with any other residents. Although the actual circumstances that led to the altercation wasn't witnessed, staff did observe R2 dragging R1 out of his room and dragging R1 down the hall, bleeding from her head area with a laceration to her forehead and a large hematoma. The staff interviewed acknowledged memory care resident R1 had “peeked” into the incorrect room occasionally but would appear to realize she was at the wrong room and then proceed down the hall. There were no witnesses tRead the full finding— CDSS inspection report, September 22, 2025 · control 08-AS-20220714082610

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Mike McCoy. On January 21, 2025, it was alleged that neglect/lack of supervision resulted in laceration and residents bed rails were in disrepair. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews. According to the allegation received, Resident #1 (R1) was being wheeled in their wheelchair to their bedroom by staff. When the resident got to their bedroom door they fell out of their wheelchair and sustained a head laceration. It was also alleged that the bed rails on R1’s bed were not secured. [Continued on LIC9099-C] SubstantiatedRead the full finding— CDSS inspection report, June 5, 2025 · control 08-AS-20250121105214

Licensing Program Analyst (LPA) Iby Strong made an unannounced visit to open an investigation on the above-mentioned allegations. LPA met with Executive Director Michael McCoy and discussed the basic elements of the complaint. According to allegations, Resident 1’s (R1) care was neglected resulting in infections and R1’s room was unsanitary. During the investigation, LPA Strong collected facility records, conducted interviews and completed a facility visual inspection. According to the first allegation, R1 was moved out of the facility in February of 2025 after R1 sustained a urinary track infection and viral infection. Records collected revealed that R1 lived at the facility from October 28, 2024, until November 9, 2024, a total of nine days. Interviews with staff present established that R1 was moved out of the facility because responsible party was requesting a private room, and none was available. UnsubstantiatedRead the full finding— CDSS inspection report, April 29, 2025 · control 08-AS-20250423154013

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] SubstantiatedRead the full finding— CDSS inspection report, February 24, 2025 · control 08-AS-20240725111316

Licensing Program Analyst (LPA) Ryan Fulton conducted an unannounced 10-day visit to initiate a complaint investigation and deliver findings regarding the above mentioned allegation. LPA introduced himself and disclosed the purpose of the visit to Resident Services Director Nae Brownell. On 07/09/24, it was alleged that staff left resident in a soiled diaper for a prolonged period of time. The Department’s investigation consisted of an unannounced facility visit, interviews with facility staff and residents, and a records review. Staff interviews revealed that the facility was changing residents promptly. Staff said they check resident rooms every two hours for incontinence care issues. Staff members advised that while some residents need more attention with incontinence care, they believe all residents receive the appropriate amount of care. Staff interview revealed that incontinence products were located in a locked storage room that is accessible to staff. Resident Interviews did noRead the full finding— CDSS inspection report, August 21, 2024 · control 08-AS-20240709103241

Licensing Program Analysts (LPA) Iby Strong and Ryan Fulton conducted an unannounced visit to initiate a complaint investigation. LPAs identified themselves and discussed the purpose of the visit with Resident Services Director Nae Brownell. On July, 9, 2024, Community Care Licensing (CCL) received a complaint alleging staff lack of supervision resulted in resident on resident altercations. During investigation, LPA Strong collected pertinent resident records as well as facility documentation and conducted interviews. Based on Resident 1 (R1) Physician’s Report dated April 2, 2024, R1 can communicate need and can follow instructions. According to allegations, on two separate occasions, residents were not supervised resulting in R1 being hit by Resident 2 (R2) causing R1 a minor injury then and on a separate occasion R1 was scratched by Resident 3 (R3). UnsubstantiatedRead the full finding— CDSS inspection report, July 16, 2024 · control 08-AS-20240709113951

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Amanda Togia, Business Office Director. On 2/28/23 the following allegations were made against the Licensee: Neglect/lack of supervision resulting in sexual abuse, neglect/lack of supervision resulting in felony drug use, Licensee retained residents who were incompatible with other residents in care. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "Neglect/lack of supervision resulting in sexual abuse", it was alleged that staff did not prevent Resident (R1) from taking sexual advantage of Resident 5 (R5), and staff did not prevent Resident 3 (R3) from inappropriately touching Resident 6 (R6). Staff members interviewed consistently denied that either evRead the full finding— CDSS inspection report, May 31, 2024 · control 08-AS-20230228111919

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigation findings. LPA was granted entry into the facility and met with Stefanie Ancheta, Executive Director, to whom LPA disclosed the reason for the visit. It was reported to Community Care Licensing that Resident 1 (R1) had a seizure for which 9-1-1 was not called. It was also reported that Resident 2 (R2) fell and hit his/her head, following which staff arrived 30 minutes later and put R2 back into the bed without conducting an assessment or calling 9-1-1. Community Care Licensing (CCL) has investigated the above-listed complaint allegation. The investigation consisted of a tour of the facility, review of facility records, and interviews of staff and outside source. Records obtained and reviewed during the investigation reflected that R1 had documented seizure activity. It was also noted that R1 was transported to the hospital, on occasion, following seizure activity. It was further UnsubstanRead the full finding— CDSS inspection report, March 27, 2024 · control 08-AS-20230429075042

Licensing Program Analyst (LPA) Daniel Pena conducted an unannounced complaint visit. LPA gained access to the facility and met with Administrator, Stefanie Ancheta and explained the purpose of the visit which was to initiate a complaint investigation. Upon conclusion of the facility visit, LPA delivered findings for the above allegation to Ms. Ancheta. The Department’s investigation consisted of visits to the facility, resident records reviews and interviews with pertinent staff and outside sources. It was alleged Resident 1 (R1) was unlawfully evicted from the facility. Record reviews indicated that R1 had displayed aggressive behaviors towards residents and staff four times. R1’s changes in behavior were documented in appraisals, physician reports and physician progress notes. R1’s aggressive behaviors caused injury to residents. Upon move in, R1’s Power of Attorney signed the facility’s admission agreement which reads in part, "#3 Residents must not engage in conduct that poses a dRead the full finding— CDSS inspection report, February 28, 2024 · control 08-AS-20240221104203

Licensing Program Analyst (LPA) Daniel Pena conducted a visit to the facility to initiate a complaint investigation. After identifying himself and providing the purpose of the visit, LPA was allowed into the facility where he was met by Administrator, Stefanie Ancheta. Upon the conclusion of the visit, LPA provided Ms. Ancheta with investigative findings. On 02/27/2024, the Department received this complaint which alleges; Staff did not ensure resident was provided with adequate bed linens; Staff did not adequately assist resident with activities of daily living; and Staff did not inform resident's physician of a change in resident's condition. The Department's investigation consisted of facility inspection, LPA observation, record reviews and interviews with staff and outside sources. LPA, accompanied by Ms. Ancheta, toured the facility's memory care unit. LPA observed that each of the resident's bed obsereved had linens which appeared clean and without foul odor. LPA observed the facRead the full finding— CDSS inspection report, February 28, 2024 · control 08-AS-20240227093832

Licensing Program Analyst (LPA) Mark Mandel conducted an unannounced visit to follow-up on a complaint investigation regarding the above-mentioned allegations. LPA was greeted by, identified himself to and was granted entry by Business Office Director, Amanda Togia. LPA stated the purpose of the visit and discussed the elements of the complaint with Director Togia. LPA delivered the investigative findings to Director Togia. Today's visit consisted of staff interviews and records review. The Department’s investigation consisted of facility visits, record reviews, and interviews with staff, residents and outside sources. On 12/28/2023, the Department received a complaint alleging that facility staff do not report incidents to the appropriate parties; however, the only incident that was spefically described and corrobated to have occurred after interviews with staff was determined to have been reported to all the appropriate parties. A review of the number of Unusual Incident Reports repoRead the full finding— CDSS inspection report, February 1, 2024 · control 08-AS-20231228124435

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Executive Director Stefanie Ancheta. On 3/29/23 it was alleged that lack of supervision resulted in a resident sustaining an injury when a resident (R1) had an episode of physical aggression against another resident (R2). The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, and outside sources. Staff interview revealed that residents R1 and R2 were directly observed by staff (S1) at 4:00pm and found to be at baseline with no visible injuries; residents were checked again at 4:30pm and R2 was found with minor injuries, noted as bruises. Records review revealed that on the day of the event, R2 had been visited by an outside agency for care and an outside individual for visitaRead the full finding— CDSS inspection report, November 6, 2023 · control 08-AS-20230329120448

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Executive Director Stefanie Ancheta. On 6/21/23 it was alleged that staff did not meet residents' needs due to residents having to wait long periods of time for their meals. The Department’s investigation consisted of unannounced facility tours, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Staff interviewed had not observed delays in food service and had not been notified by residents or their responsible parties of food delays. Staff interview revealed that over the past few years the breakfast time has changed from 7:30am, to 8:00am, to 8:30am, possibly causing confusion between residents and staff regarding what time breakfast is served. Residents interviewed provided mixed opinions regardRead the full finding— CDSS inspection report, November 6, 2023 · control 08-AS-20230621145001

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Executive Director Stefanie Ancheta. On 6/6/23 it was alleged that Licensee did not address Scabies outbreak, and Licensee did not assist resident(s) with showers. The Department’s investigation consisted of unannounced facility visits, review of facility records, interviews with facility staff, residents, outside sources, and LPA direct observations. Regarding the allegation, "Licensee did not address Scabies outbreak", it was alleged that Licensee did not take measures to prevent Scabies from spreading at the facility. Staff interview revealed that staff identified the first cases, elevated the issue, and management trained/implemented the infection control protocol the same day of the first confirmed case. All staff interviewed consistently recited the infection control protocolRead the full finding— CDSS inspection report, November 6, 2023 · control 08-AS-20230606163351

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and disclosed the purpose of the visit to Executive Director Stefanie Ancheta. On 4/4/23 it was alleged that the facility did not administer medication to a resident as prescribed, and that lack of supervision resulted in a residents' elopement. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, and outside sources. Regarding the allegation, "Facility did not administer medication to a resident, as prescribed", it was alleged that a resident (R1) received a pro re nata (PRN) medication too soon within the prescription orders, and did not receive a medication after the facility received it. Staff interview and records review revealed that R1 received the PRN within the required timeframes on the day in question. (Read the full finding— CDSS inspection report, November 6, 2023 · control 08-AS-20230404114645

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation(s). LPA was welcomed by and discussed the purpose of the visit with Executive Director Stefanie Ancheta. On 2/15/23, it was alleged that staff did not administer medication as prescribed, and Licensee did not ensure resident(s) had access to personal care supplies. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations. Regarding the allegation, "Staff did not administer medication as prescribed", it was alleged that a staff member intentionally withheld a resident's pro re nata (PRN) medication when the resident needed it. Staff interview revealed that the resident in question received the PRN medication the day of the incident and that staff monitor residents, assisting with their behaviors whenRead the full finding— CDSS inspection report, November 6, 2023 · control 08-AS-20230215104856

Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegations. LPA was granted entry to the facility by Stefanie Ancheta, Administrator, after identifying herself and explaining the reason for the visit. On May 31, 2022, it was alleged that staff did not administer medication as prescribed, staff did not assist residents with showering, staff did not provide incontinence care, there were insufficient number of staff resulting in resident falls, and staff did not follow COVID-19 infection control requirements. The Department’s investigation consisted of review of facility records, outside source records, and interviews of facility staff and outside sources. Regarding the allegation that staff did not administer medication as prescribed, LPA randomly selected [Continued on LIC9099-C, Page 1 of 4] UnsubstantiatedRead the full finding— CDSS inspection report, June 23, 2023 · control 08-AS-20220531161724

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced facility visit to investigate the above mentioned complaint allegation. LPA identified herself and met with Amanda Togia, Business Office Director, to discuss the purpose of the visit and elements of the complaint. On 5/17/23 it was alleged that the Licensee illegally evicted a resident (R1). The Department’s investigation consisted of an unannounced facility tour, review of facility and outside source records, and interviews with facility staff and outside sources. Interviews with staff, outside sources, and record review showed that R1 no longer fit the criteria for living in an RCFE community. R1 had been vocal about their desire to no longer live at the facility and to leave to find another residence. Staff interview revealed that the Executive Director inquired with Community Care Licensing, the resident's primary care physician and psychiatrist, Adult Protective Services, Oceanside Police Department, and thRead the full finding— CDSS inspection report, May 24, 2023 · control 08-AS-20230517100748

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Business Office Director, Amanda Togia, Resident Service Director, Yesenia Reyes. Throughout the investigation, the Department secured pertinent records and conducted interviews with internal and external sources. It was alleged staff did not clean the facility. It was reported to the department staff did not maintain the facility, residents’ rooms and bathrooms clean. Interviews with internal and external sources revealed facility floors, resident rooms and bathroom were witnessed to be dirty. Care staff not having access to cleaning supplies resulted in these areas to be uncleaned. Observations by the LPA on multiple visits to the facility corroborated facility floors, residents’ rooms, and bathroom were not clean. SubstantiatedRead the full finding— CDSS inspection report, May 18, 2023 · control 08-AS-20230228142235

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to commence a complaint investigation. LPA introduced herself, was granted entry into the facility, and met with Stefanie Ancheta, Executive Director, to whom LPA disclosed the reason for the visit. During the visit, LPA toured the facility, reviewed facility records, and spoke with resident, facility staff and outside source. It was alleged that the facility does not provide food to meet the dietary needs of residents in care. It was reported that meals are being prepared and offered to residents; however, if residents choose not to eat the meal being served, staff members eat the meals and residents are left with no food. While touring the facility, LPA observed meals prepared for lunch service to the residents, which consisted of the same food items as was listed on the facility’s weekly main menu. Interviews revealed and LPA observed an a la carte menu, with a variety of food choices, including sandwiches, bRead the full finding— CDSS inspection report, May 4, 2023 · control 08-AS-20230429073516

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Stefanie Ancheta. During today's visit, LPA conducted interviews with staff and the Executive Director. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that facility staff did not observe a resident’s change in condition specifically regarding a resident fall. Interviews and record review revealed that Resident 1 (R1) was non-ambulatory, used a wheelchair, was unable to independently transfer, and was determined to be a fall risk. Continued on LIC9099-C page... UnsubstantiatedRead the full finding— CDSS inspection report, April 25, 2023 · control 08-AS-20230327094641