Heritage Estates

Type of visit: Required - 1 Year

On 8/26/2026 at 9:00AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Susan Donaghy and explained the reason for the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced in November of 2025. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food supplies twice a week. Freezer’s temperature was registered at -0 degree F while the refrigerator’s temperature was recorded at 39 degrees F. There is currently an active work order for Hot water temperature as it is measuring below 105 degrees Farenheit. Grab bars and non-skid mats were observed. There were adequate lights in each room. The facility has a written emergency disaster plan. Last fire drill was conducted on 7/21/2026. LPA observed stairwells have evacuation chairs. LPA reviewed 5 residents and 5 staff files. All staff are fingerprint cleared and associated to the facility. LPA reviewed a sample of resident's medications during inspection. No deficiencies are being cited on this date. Exit interview conducted with Susan. A copy of this report provided.the state’s words, verbatim · CDSS document, Aug 26, 2026

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff neglecting resident

On 07/16/26 at 12:35PM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, met with staff (GM, ADM), gathered information and delivered investigation finding to staff. LPA explained the purpose of the visit with staff. On 07/07/26 and 07/16/26, LPA D Panlilio conducted interviews with reporting party (RP), staff (GM, ADM), reviewed and obtained the following documents: Personnel record (LIC500), Residents roster, R1's admission agreement, appraisals /needs & services plan, physician's report, written 30-day eviction letter and incident reports. Continue on next page, LIC 9099-C Unsubstantiated Allegation: Staff are neglecting resident Investigation Finding: Unsubstantiated During investigation, LPA D Panlilio conducted interviews with reporting party (RP), facility staff (GM, ADM) and reviewed resident (R1) documents. Review of R1’s admission agreement showed he has been living at the facility since 07/09/2018. On 07/07/26, LPA interviewed RP who stated that staff did not abuse or neglect R1. RP stated they received a written 30-day eviction notice from the facility on 07/02/26 due to R1’s higher level of care needs and steady decline. On 07/16/26, LPA interviewed staff (GM, ADM) who denied neglecting R1’s care and supervision. GM and ADM confirmed with LPA that they issued a written 30-day eviction notice to R1 and his responsible party (POA) on 07/02/26 due to his change in condition which requires a two-person assist with his activities of daily living (ADLs). GM and ADM stated they continue to work closely with R1 and his POA in finding a safe alternative location to meet his higher level of care needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff are neglecting resident is unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 15-AS-20260707165807

Type of visit: Case Management - Incident

On 10/22/2025 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 10/2/2025. LPA met with General Manager, Michael Fillari and informed him the reason for the visit. Health and Wellness Director, Susan Donaghy arrived an hour later. Based on the incident report received on 10/2/2025, family member informed the facility that resident (R1) alleged a staff slapped R1 multiple times. Facility staff checked R1 for any injuries. R1 was not able to identified the staff involved. Facility notified local police and ombudsman. During visit, LPA reviewed R1's file and observed R1 was diagnosed with MCI (Mild Cognitive Impairment). LPA interviewed resident and staff. LPA obtained R1's physician's report, care plan, care notes, and emergency information. LPA may return at a later time. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Oct 22, 2025

Type of visit: Case Management - Incident

On 9/10/2025 at 3:20PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 8/30/2025. LPA met with General Manager, Michael Fillari and informed him the reason for the visit. Based on the incident report received on 8/30/2025, resident (R1) was heard calling for help from the apartment and S2 observed R1 on the floor. R1 stated she lost her balance and fell while in the middle of dressing. S2 called 911 and notified R1's family. R1 was diagnosed with a fractured femur and some broken ribs. During visit, LPA reviewed R1's file and observed R1 was independent for majority of ADL care. R1 needed some assistance with care. LPA interviewed S2 and was informed R1 had an unwitnessed fall. R1 is current at a Rehabilitation Center. S2 stated R1 will be re-assessed upon returning to the facility. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Sep 10, 2025

Type of visit: Required - 1 Year

On 7/16/2025 at 9:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with General Manager, Michael Fillari and Health & Wellness Director, Susan Donaghy. LPA explained the reason for the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 3/5/2025. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food supplies twice a week. Freezer’s temperature was registered at -2 degree F while the refrigerator’s temperature was recorded at 32 degrees F. Hot water temperature was measured at 113.9 degrees F in a resident's bathroom sink. Grab bars and non-skid mats were observed. There were adequate lights in each room. The facility has a written emergency disaster plan. Last fire drill was conducted on 6/2/2025. LPA observed stairwells have evacuation chairs. LPA reviewed 5 residents and 5 staff files starting at 10:30AM. All staff are fingerprint cleared and associated to the facility. LPA reviewed a sample of resident's medications during inspection. No deficiencies are being cited on this date. Exit interview conducted with Susan. A copy of this report provided.the state’s words, verbatim · CDSS document, Jul 16, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff mismanaged resident's medication Staff did not notify resident's authorized representatives of incidents

On 2/26/2025 at 1:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegations above. LPA met with Health and Wellness Director, Susan Donaghy and explained the purpose of the visit. During the investigation, LPA interviewed staff and complainant. LPA reviewed and obtained documents including email correspondence, emergency information, care plan, care notes, MAR (Medication Administration Record), resident incident reports, hospice information, and death report. Staff mismanaged resident's medication After reviewing a sample of residents' MAR, LPA observed the residents were prescribed Tamiflu after being diagnosed with influenza. Doctor's order indicated that Tamiflu medication should be given 1 capsule by mouth 2 times a day for 5 days. Resident's MAR revealed that medication was given accordingly. (continue on LIC9099C...) Unsubstantiated Staff did not notify resident's authorized representatives of incidents Interview with complainant indicated that family was not notified when R2 was sick. However, LPA observed facility's resident incident report documented that R2's family was notified when R2 had influenza. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided. Staff are not following infectious control procedures Interview with complainant indicated that facility did not follow infectious control procedures by not notifying family members. However, LPA observed facility's resident incident reports revealed that residents' families were notified. Facility notified CCLD and health department via email. LPA observed one resident was in isolation and facility had PPEs, garbage can, and signage in front of the resident's room. This agency has investigated the complaint allegations. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 15-AS-20250224143819

Type of visit: Case Management - Health Checks

On 2/26/2025 at 11:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a health and safety check as a result of a priority 1 complaint. LPA met with Health and Wellness Director, Susan Donaghy and informed her the reason for visit. LPA toured facility including but not limited to resident's bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 112.8 degrees F in a resident's bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility purchase food twice a week. Freezer temperature was measured at 0 degrees F and refrigerator temperature was measured at 39 degrees F. Resident's medications were kept locked in the medication cart located in the medication room. Smoke and Carbon monoxide detectors observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 1/23/2025. There are no accessible bodies of water observed. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 26, 2025

Allegation investigated: Facility is not able to meet the needs of the resident. Staff member threatens resident in care. Staff member prohibits resident from seeking medical attention when needed. Facility does not have enough staff to meet the needs of resident in care.

On 12/27/2024 at 12:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegations above. LPA met with General Manager, Michael Fillari and explained the purpose of the visit. During the investigation, LPA interviewed 4 residents, 5 staff, and witness. LPA reviewed and obtained documents including staff schedule, emergency information, physician's report, care plan, care notes, incident reports, and call button logs. Facility is not able to meet the needs of the resident. After reviewing R2's physician's report and care plan, the physician's report stated that R2 is capable of self-care for bathing, toileting, grooming, dressing, and feeding. R2's care plan states that R2 is independent for toileting, dressing, grooming, and transfers. However, care notes have revealed that R2 was assisted with transfers when needed. (Continue on LIC9099C...) Unsubstantiated Staff member threatens resident in care. Interview with staff and residents revealed that staff have not threaten residents. Residents stated that staff are friendly to residents. Staff member prohibits resident from seeking medical attention when needed. Interview with staff indicated that residents have access to a phone, pendent, and pull cord to get assistance or medical attention. Interview with residents revealed that staff have not prevented residents from seeking medical attention when needed. Facility does not have enough staff to meet the needs of resident in care. Interview with staff indicated there are 4-5 staff for morning shift, 4 staff for afternoon shift, and 2 staff for night shift. Staff stated that the resident's needs are being met. Interview with residents revealed that staff is available when needed. Staff schedule indicates there are additional staff to cover for those staff who calls in sick or are on vacation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Dec 27, 2024 · control 15-AS-20240213095509

Type of visit: Case Management - Deficiencies

On 12/27/2024 at 5:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with General Manager, Michael Fillari and explained the purpose for the visit. While LPA G. Luk was at the facility for a complaint investigation (#15-AS-20240213095509), the following deficiency was observed. During the complaint investigation, LPA observed the call button response time shows there were several incidents where the resident waited more than 30 minutes for staff assistance. Interview with staff and residents revealed that the facility is short staff resulting in residents waiting longer for staff assistance. It was noted that wait time can be 20-40 minutes for staff to respond to call button. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 27, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 13, 2025

Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers...to provide the services necessary...In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care... Based on investigation, the licensee did not comply with the section cited above by not responding to call button in a timely manner which poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Dec 27, 2024

Plan of correction: General Manager (GM) has agreed to provide a written plan to address the long response time for call button. GM will submit the written plan to CCLD by POC date.

Type of visit: Case Management - Incident

On 8/21/2024 at 2:50PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to incident report received on 7/24/2024. LPA met with Health & Wellness Director, Susan Donaghy and informed her the reason for the visit. Based on the incident report received on 7/24/2024, resident (R1) determined that she was missing money from her wallet. Facility contacted R1's family and reported to Ombudsman and CCLD. During visit, LPA reviewed and obtained R1's file including physician's report, incident report, and care notes. R1 was out in the community at the time of visit. Interview with staff revealed that staff assisted R1 in looking for the missing money. However, staff was unable to find the missing money. LPA may return at a later time. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Aug 21, 2024

Type of visit: Required - 1 Year

On 8/1/2024 at 10:20AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with General Manager, Michael Fillari and Health & Wellness Director, Susan Donaghy. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in different carts located in the med room. First Aid kit is complete. The facility has a written emergency disaster plan. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 2/1/2024. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility orders food supplies twice a week. Freezer’s temperature was registered at -2 degree F while the refrigerator’s temperature was recorded at 40 degrees F. Hot water temperature was measured at 112 degrees F in a resident's bathroom sink. Grab bars and non-skid mats were observed. There were adequate lights in each room. Indoor and outdoor passages were free of obstruction. Last fire drill was conducted on 7/25/2024. LPA reviewed 5 residents and 5 staff files starting at 12:30PM. LPA interviewed 4 residents and 4 staff starting at 3:00PM. LPA reviewed a sample of resident's medications starting at 4:00PM. At 4:15PM, LPA observed R5 did not have Baqsimi nasal spray and Hydroxyzine HCL PRN medications available. Record review shows that the two medications were in R5's current MAR. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 1, 2024

Allegation investigated: Lack of supervision/neglect of residents Uncleared person at the facility Personal rights: Staff taking resident's groceries

On 2/16/2024 at 2:40PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings regarding the allegations above. LPA met with General Manager, Michael Fillari and informed him of the reason for the visit. During the course of investigation, LPA interviewed resident, staff, and witnesses. LPA obtained and reviewed independent living resident roster. Interview with resident and witnesses revealed that R1 lives in the independent side of the facility. Witnesses stated that caregivers were hired by R1's family members. This agency has investigated the complaint allegations. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Feb 16, 2024 · control 15-AS-20240215164746

Allegation investigated: Staff physically abused resident at the facility

On 12/18/2023 at 10:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings regarding the allegation above. LPA met with General Manager, Michael Fillari and informed him of the reason for the visit. During the course of investigation, LPA interviewed resident, staff, and witness. LPA obtained and reviewed documents including physician's report, care plan, and POA documents. Interview with resident and witness revealed the caregiver that hit R1 was from an outside agency and was not a facility caregiver. W1 stated that the caregiver was hired by R1's POA and is a private caregiver for R1 only. The Department will cross report to appropriate agency. This agency has investigated the complaint allegation. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided. Unfoundedthe state’s words, verbatim · CDSS document, Dec 18, 2023 · control 15-AS-20231214155404

Type of visit: Case Management - Health Checks

On 12/18/2023 at 12:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. LPA met with General Manager, Michael Fillari and informed him the reason for visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 112.3 degrees F in a hallway bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility purchase food twice a week. Freezer temperature was measured at -3 degrees F and refrigerator temperature was measured at 39 degrees F. Resident's medications were kept locked in the medication cart located in the medication room. Medication room is locked. Smoke and Carbon monoxide detectors observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 2/1/2023. There are no accessible bodies of water observed. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 18, 2023