Heritage Residence

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:50 am to conducted a 1 year annual visit to the facility above. LPA met with Administrator Ling Manuel and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has an Infection Control Plan on file. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms when and if needed. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: The facility has 4 resident bedrooms, 1 bedroom has an on suite bathroom and 1 common are restroom currently occupying 4 residents and employs 4 staff, 1 Administrator and 3 back up staff. The facility has 1 bedroom for live-in staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents and are locked under the kitchen sink and in the locked garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for resident use with an umbrella for shade. Telephone and internet service is provided for resident use. The facility has a working washer and dryer. Continued 809-C Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 09/11/2026. The facility is approved for a capacity of 4 with 4 Non-Ambulatory of which 1 may be bedridden in bedroom #2. Hospice approved for 3. Water was tested in main restroom and measured at 117.1F. Fire Extinguishers were charged and last inspected on 01/19/2026. Staffing: The facility employes 2 full time live in staff caregivers, 3 back up care staff, 1 administrator and 2 back up Administrators as well as 2 maintenance staff. Staff records are kept confidential. LPA reviewed 4 staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate expires 09/23/2026, Back up Administrators Administrator Certificates Expires 11/23/2027 and 09/23/2026. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 4 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness, policy, procedures, infection control, and PPE requirements. Quarterly Disaster Drills are completed. Staff handling medications had annual training. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health had training records on file. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license is posted. Visitation policy is posted at entry. Internet is provided to residents in care with confidentiality and privacy. Continued 809-C Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices. Incidental Medical Services: Facility provides or assist in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications for all resident in care are centrally stored. LPA reviewed medications and records for all 4 residents in care. No medications label were altered, medications were checked for expiration dates, medications are stored in original containers and medications were given as prescribed with physicians orders. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Facility has emergency food and water supply, flash lights with batteries, and a cooler with ice packs for medications. The facility has two evacuation locations and a three places available for a back up generator if sheltering in place. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have any residents currently using oxygen. The facility currently has 1 resident receiving hospice services. The facility currently has 1 resident receiving home health services. Hospice and Home Health care plans are kept on file and up to date. The facility does not have any delayed egress. The facility has two self latching, self closing gates with alarms. All exiting doors and gates are alarmed. LPA conducted interviews with 2 staff and none of the residents were able to provide interview. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Sep 3, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 2:25 pm to conducted a 1 year annual visit to the facility above. LPA met with Administrator Ling Manuel and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has an Infection Control Plan on file. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms when and if needed. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: The facility has 4 resident bedrooms and 2 resident bathrooms currently occupying 4 residents and employs 5 staff. The facility has 1 bedroom for live-in staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents are locked under the kitchen sink and in the locked garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with an umbrella for shade. Telephone and internet service is provided for resident use. The facility has a working washer and dryer. Continued 809-C Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 09/11/2025. The facility is approved for a capacity of 4 with 4 Non-Ambulatory of which 1 may be bedridden in bedroom #2. Hospice approved for 3. Staffing: The facility employes 2 full time live in staff, 2 back up staff, 1 administrator and 2 back up Administrators. Staff records are kept confidential. LPA reviewed 4 staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate expired 09/23/2026, Back up Administrators Administrator Certificates Expires 11/23/2025 and 09/23/2026. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 4 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness, policy, procedures, infection control, and PPE requirements. Quarterly Disaster Drills are completed. Staff handling medications had annual training. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health had training records on file. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license is posted. Visitation policy is posted at entry. Internet is provided to residents in care with confidentiality and privacy. Continued 809-C Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices. Incidental Medical Services: Facility provides or assist in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications for all resident in care are centrally stored. LPA reviewed medications and records. No medications label were altered, medications were checked for expiration dates and medications were given as prescribed with physicians orders. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Facility has emergency food and water supply, flash lights with batteries, and a cooler with ice packs for medications. The facility has two evacuation locations and a three places available for a back up generator if sheltering in place. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have any residents currently using oxygen. The facility currently has 2 resident receiving hospice services. The facility currently does not have resident receiving home health services. Hospice care plans are kept on file and up to date. The facility does not have any delayed egress. The facility has two self latching, self closing gates with alarms. All exiting doors and gates are alarmed. There are no bodies of water on the premises. LPA conducted interviews with 2 staff and 2 residents. Exit interview conducted and copy of report printed for Administratorthe state’s words, verbatim · CDSS document, Sep 3, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 1:00 pm to conducted a 1 year annual visit to the facility above. LPA met with Administrator Ling Manuel and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has an Infection Control Plan on file. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms when and if needed. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environment Safety: The facility has 4 resident bedrooms and 2 resident bathrooms currently occupying 3 residents and employs 8 staff. The facility has 1 bedroom for live-in staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents are locked under the kitchen sink and in the locked garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with an umbrella for shade. Telephone and internet service is provided for resident use. The facility has a working washer and dryer. Continued 809-C Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 09/11/2025. The facility is approved for a capacity of 4 with 4 Non-Ambulatory of which 1 may be bedridden in bedroom #2. Hospice approved for 3. Staffing: The facility employes 2 full time live in staff, 4 back up staff, 1 administrator and 1 back up Administrators. Staff records are kept confidential. LPA reviewed 4 staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate expired 09/23/2024, renewal application has been submitted and is pending. Back up Administrator Administrator Certificate Expires 11/23/2025. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 4 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness, policy, procedures, infection control, and PPE requirements. Quarterly Disaster Drills are completed. Staff handling medications had annual training. Trainers met the requirements to train staff with required information present in files. Hospice and Home Health had training records on file. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Three files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license is posted. Visitation policy is posted at entry. Internet is provided to residents in care with confidentiality and privacy. Continued 809-C Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices. Incidental Medical Services: Facility provides transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications for all resident in care are centrally stored. LPA reviewed medications and records. No medications label were altered, medications were checked for expiration dates and medications were given as prescribed with physicians orders. Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Facility has emergency food and water supply, flash lights with batteries, and a cooler with ice packs for medications. The facility has two evacuation locations and a three places available for a back up generator if sheltering in place. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have any residents currently using oxygen. The facility currently has 3 resident receiving hospice services. The facility currently does not have resident receiving home health services. Hospice care plans are kept on file and up to date. The facility does not have any delayed egress. The facility has two self latching, self closing gates with alarms. 1 gate is in need of repair to self latch again. All exiting doors and gates are alarmed. There are no bodies of water on the premises. LPA conducted interviews with 2 staff and 2 residents. Exit interview conducted and copy of report printed for Administratorthe state’s words, verbatim · CDSS document, Oct 17, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff does not provide adequate supervision resulting in residents wandering away from facility.

Licensing Program Analyst (LPA) De Leon conducted 10-day Complaint visit to the facility above. LPA met with Administrator Ling Manuel and explained the purpose of the visit. LPA requested Resident 1 (R1's) preplacement Appraisal, LIC.602A Physicians report, Appraisal Needs and Services Plan, staff roster, residents roster and incident report. LPA conducted interview with Administrator, Staff 1 (S1) and R1. On the allegation: Staff does not provide adequate supervision resulting in residents wandering away from facility. LPA interviewed S1 which revealed that R1 was exit seeking on 09/28/2023 and when staff 2 (S2) went into the restroom and S1 went to help another resident, R1 opened and went out the front door, the alarm went off and S1 went to the front door to see what was going on when S1 observed R1 across the street with 2 neighbors, S1 went back inside and grabbed S1's cell phone then proceeded outside across the street meeting up with R1 and 2 neighbors and they all walked with each other bringing R1 back to the facility. Continued 9099 Substantiated Administrator stated she was not here on 09/28/2023, R1 is a new resident was admitted on 09/04/2023, on 09/26/2023 R1 was exit seeking and went out the front door followed by Administrator R1 did not AWOL Administrator had eyes on R1 at all times, S1 did call Administrator on 09/28/2023 and reported R1 was exit seeking and went out across the street with neighbors and had to be redirected back to the facility. R1's interview revealed R1 wants to leave the facility and S1 was trying to redirect R1 inside the facility but once S1 was with another resident R1 left out the front door and crossed the street when 2 neighbors approached R1, then S1 came outside and they all walked R1 back to the facility, R1 was OK, R1 did not have any injuries and does not want anyone to get in trouble. R1 was always able to leave R1's home and is not understanding why R1 can not leave the facility, it was explained to R1 that R1 can leave the facility but needs to let the staff know so they can assist R1 on a walk when R1 wants to go outside. Administrator contacted R1's family and doctor regarding the exit seeking and medications have been adjusted to help with wandering. Administrator stated the facility has not had any another incidents of resident AWOL over the past month only exit sekking and wandering with staff supervision and redirection. Based on the evidence this allegation is Substantiated at this time. Administrator has placed a door stop alarm at the front door for further safety measures. Administrator is observing R1 with medication adjustments and taking R1 for walks to help with the wandering behaviors. Administrator will be looking into locked exiting doors and secured perimeter fence gates with the local fire authority to see if the facility would qualify to update the fire clearance with added safety measures. Administrator will also talk with R1's family regarding a wonder guard or apple air tag bracelet for added safety measures for R1. Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for Administrator.the state’s words, verbatim · CDSS document, Oct 2, 2023 · control 29-AS-20230929150014

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 3, 2023

(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 interviews the licensee did not comply with the regulation above, R1 was able to leave through the alarmed front door and walk across the street off of the property before staff was able to follow and redirect R1 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: The administrator agreed to hold an all-staff training for supervision of residents, duties, responsibilities, elopement procedures, and on audible alarm sounds and responses. Provide proof of training with all staff signatures and an up to date LIC 500 to CCL. Repeat Violation-Civil Penalty Assessed.