Inspection Reports for Heritage Gardens

Licensing Program Analysts conducted an unannounced required annual inspection of the Heritage Gardens Residential Care Facility for Elderly to assess compliance with regulations.

The facility was generally well maintained with adequate physical plant conditions, food service, and health-related services; however, deficiencies were cited for medication administration practices and incomplete staff files.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff unlawfully evicted a resident.

The investigation found the allegation to be unfounded, meaning it was false, could not have happened, and/or was without a reasonable basis. Interviews and file reviews confirmed that the resident received an eviction notice but continues to reside at the facility while efforts to find suitable housing continue.

The complaint alleged that staff unlawfully evicted a resident. The investigation concluded the allegation was unfounded.

An unannounced complaint investigation was conducted following a complaint received on 2025-01-14 alleging that facility staff did not seek timely medical attention for a resident in care.

The investigation found the allegation to be unfounded based on record review and interviews, indicating the allegation was false or without reasonable basis.

The complaint was that facility staff did not seek timely medical attention for a resident. The allegation was determined to be unfounded.

An unannounced complaint investigation was conducted in response to allegations received on 2024-12-20 regarding staff not responding timely to call buttons, not following diet plans, restricting restroom use, pest control issues, and bathroom cleanliness.

The investigation found the allegations to be unfounded after interviews and record reviews, including verification that the resident in question did not reside at the facility but at a skilled nursing facility.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or lacked reasonable basis.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation that the facility does not serve food of good quality to residents and does not adhere to the displayed daily menu.

The allegation was found to be unsubstantiated after review of food supply, receipts, menu, and interviews with staff and residents. Staff reported that the menu rarely changes unexpectedly and residents confirmed this during interviews.

The complaint alleged that the facility does not ensure food of good quality and does not stick to the provided daily menu. The investigation found no preponderance of evidence to prove the alleged violation; the complaint was unsubstantiated.

An unannounced complaint investigation was conducted in response to an allegation that staff do not ensure residents' needs are met.

The investigation included interviews with staff and residents, record reviews, and observations. The allegation was found to be unsubstantiated as evidence did not support that residents' needs were unmet.

The complaint was unsubstantiated based on interviews with 5 staff and 7 residents, observations, and record reviews. Some residents reported needs were met, others reported they were not, and some were unable to answer. Overall, there was no preponderance of evidence to prove the alleged violations.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations received on 2024-06-27 regarding meal service availability, medication administration, visitor rights infringement, and unauthorized individuals residing in residents' rooms.

The investigation found the allegation that staff did not ensure dinner was available to residents to be unfounded. The allegations regarding medication administration, visitor rights infringement, and unauthorized individuals residing in residents' rooms were unsubstantiated due to insufficient evidence.

The complaint investigation addressed multiple allegations: staff not ensuring dinner availability, failure to administer medication as prescribed, allowing visitors to infringe on residents' rights, and unauthorized individuals residing in residents' rooms. The first allegation was found to be unfounded, while the others were unsubstantiated.

The inspection was conducted as an unannounced complaint investigation visit triggered by complaints received on 2024-03-15 regarding resident care and safeguarding of resident belongings.

Two allegations were investigated: one regarding unmet resident incontinence care needs, which was found unsubstantiated due to insufficient evidence; and another regarding failure to safeguard a resident's belongings, which was substantiated as the facility lost resident #1's dresser/mirror and night stand and reimbursed the resident for the missing furniture.

The complaint investigation was based on allegations that facility staff did not meet resident's incontinence care needs and did not safeguard resident's belongings. The incontinence care allegation was unsubstantiated, while the safeguarding allegation was substantiated with evidence including staff and resident interviews and record review.

An unannounced complaint investigation visit was conducted in response to an allegation of illegal eviction of a resident from the facility.

The investigation found insufficient evidence to substantiate the allegation of illegal eviction; therefore, the complaint was determined to be unsubstantiated.

The complaint alleged illegal eviction of resident #1. After interviews with staff, residents, outside parties, and record review, there was not enough evidence to corroborate the allegation. The complaint was unsubstantiated.

An unannounced complaint investigation was conducted in response to an allegation that staff were not providing residents their medications as prescribed.

The investigation found that six staff members denied the allegation and five out of six residents confirmed receiving their medications as prescribed. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff were intentionally not providing residents their medications as prescribed. The allegation was found to be unsubstantiated.

Licensing Program Analyst Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection.

The facility was inspected overall including physical plant, food service, care and supervision, record review, and medical related services. One deficiency was cited for failure to maintain a health screening with tuberculosis results for staff #1 (S1).

Unannounced case management visit to follow-up on an incident reported to the Community Care Licensing Division regional office on 2024-01-05 by the facility.

No deficiencies were cited during this visit. The Licensing Program Analyst obtained documentation and conducted interviews with residents and staff involved in the incident.

Licensing Program Analyst Magda Malcore made an unannounced visit to conduct a Health and Safety check to the facility.

No immediate health and safety concerns were observed; however, a deficiency was cited because the Administrator, Jaclyn Nava, did not have an Administrator Certification, though she provided verification of course completion and stated she would submit the certification application the same day.

The visit was conducted to initiate a complaint investigation related to the facility, identified by Complaint Control Number 56-AS-20230710091048.

The Licensing Program Analyst returned to the facility to make corrections to the original report. An exit interview was conducted with the administrator, and copies of reports 809 and 9099 were provided at the conclusion of the visit.

Complaint investigation initiated on 07/13/2023 with Complaint Control Number 56-AS-20230710091048. The Licensing Program Analyst returned to the facility to make corrections to the original report.

An unannounced complaint investigation visit was conducted in response to allegations including facility disrepair, residents wearing dirty clothing, and poor food quality.

The investigation found the allegations to be unsubstantiated based on interviews with residents, staff, and an outside party, as well as document review and facility tour. Issues such as dryer malfunction and hallway temperature were noted but addressed with scheduled repairs and no resident complaints.

The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations including staff dispensing medication not prescribed to residents and failure to follow residents' modified food diets.

The allegation that staff dispensed medication not prescribed to residents was substantiated, with evidence that medication was delivered to the wrong resident. One deficiency was cited related to personnel training on medication administration. The allegation that the facility did not follow residents' modified food diets was unsubstantiated, with evidence showing residents' diet preferences were being served.

The complaint was substantiated regarding medication errors where a staff member mixed up residents' medications. The complaint about failure to follow residents' modified food diets was unsubstantiated.

An unannounced visit was conducted to investigate a complaint alleging that a resident did not get dinner.

The investigation found that residents are fed three meals a day with alternatives available, and no information was found to corroborate the allegation. The complaint was deemed unsubstantiated and no deficiencies were cited.

The complaint alleging a resident did not get dinner was investigated and found to be unsubstantiated due to lack of evidence.

An unannounced visit was conducted to investigate a complaint alleging that staff were not providing a resident with diapers.

The investigation found that the facility supplied the resident with the wrong sized pull-up diapers from May 16, 2022 to June 7, 2022, causing pain to the resident. The allegation was substantiated and one deficiency was cited related to failure to provide appropriate incontinent care products.

The complaint was substantiated based on interviews and record review. The allegation that staff were not providing the resident with diapers was found valid.

An unannounced complaint investigation was conducted regarding allegations that visitors were denied entry into the facility due to COVID and that staff spoke rudely to a resident.

The investigation concluded that the resident in question does not reside at the facility and the confidential witness was not denied entry. The complaint was found to be unfounded and was dismissed.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, and/or were without a reasonable basis.

Licensing Program Analyst Javier Prieto made an unannounced visit to conduct an annual inspection with an emphasis on infection control.

The facility was found to have proper infection control measures including signage, hand hygiene supplies, PPE use, and cleaning protocols. No deficiencies were cited during the inspection.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2020-05-08 alleging staff were not providing residents with diapers and liners and not following doctors' orders.

The allegation that staff did not provide residents with diapers and liners was unsubstantiated due to lack of preponderance of evidence. The allegation that staff did not follow doctors' orders was substantiated, with evidence that treatment was missed on one day due to lack of skilled staff.

The complaint investigation included two allegations: 1) Staff are not providing residents with diapers and liners, which was unsubstantiated. 2) Staff are not following doctors' orders, which was substantiated with evidence of missed treatment on 5/10/2020.