Inspection Reports for Heritage Gardens
25271 Barton Rd, Loma Linda, CA 92354, CA, 92354
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating many concerns raised were not supported by evidence. The most recent report from February 25, 2025, cited deficiencies related to medication administration practices and incomplete staff files, though no severe enforcement actions or fines were noted. Earlier substantiated issues involved medication errors, missed treatments, and failure to provide appropriate incontinence care, but these were isolated and did not recur frequently. Complaint investigations generally did not confirm allegations, and some improvements were seen as the latest annual inspection still found medication administration problems but no new serious violations. Overall, the facility’s record shows a mix of mostly minor or isolated issues with some areas needing attention, particularly medication management and staff documentation.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
80% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 51
Capacity: 64
Deficiencies: 2
Date: Feb 25, 2025
Visit Reason
Licensing Program Analysts conducted an unannounced required annual inspection of the Heritage Gardens Residential Care Facility for Elderly to assess compliance with regulations.
Findings
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.
Deficiencies (2)
Staff are not administering medications at prescribed times or signing after administering, posing an immediate health, safety, or personal rights risk.
Seven staff files were incomplete, including one missing a health screening report signed by a physician, resulting in a technical violation.
Report Facts
Resident files reviewed: 7
Staff files reviewed: 7
Resident medications reviewed: 4
Hot water temperature: 105.9
Fire drill date: Feb 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samuel Goings | Director of Operations | Met during inspection and discussed findings. |
| Karen Clemons | Licensing Program Manager | Supervisor named in deficiency report. |
| Sarina Ramirez | Licensing Program Analyst | Conducted inspection and signed report. |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 64
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff unlawfully evicted a resident.
Complaint Details
The complaint alleged that staff unlawfully evicted a resident. The investigation concluded the allegation was unfounded.
Findings
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.
Report Facts
Facility capacity: 64
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jessica Ramos | Administrator | Met with Licensing Program Analyst during investigation and discussed findings |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 64
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
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.
Complaint Details
The complaint was that facility staff did not seek timely medical attention for a resident. The allegation was determined to be unfounded.
Findings
The investigation found the allegation to be unfounded based on record review and interviews, indicating the allegation was false or without reasonable basis.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarina Ramirez | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Jessica Ramos | Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 64
Deficiencies: 0
Date: Dec 26, 2024
Visit Reason
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.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or lacked reasonable basis.
Findings
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.
Report Facts
Capacity: 64
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarina Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Jessica Ramos | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 64
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Staff interviews conducted: 3
Resident interviews conducted: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarina Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Jessica Ramos | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 64
Deficiencies: 0
Date: Oct 22, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff do not ensure residents' needs are met.
Complaint Details
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.
Findings
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.
Report Facts
Staff interviewed: 5
Residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarina Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Mary Rico | Licensing Program Analyst | Conducted the complaint investigation |
| Jessica Ramos | Administrator | Facility administrator met during investigation and exit interview |
| Karen Clemons | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 64
Deficiencies: 0
Date: Oct 15, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 64
Census: 54
Staff interviewed: 5
Residents interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Magda Malcore | Licensing Program Analyst | Conducted the complaint investigation |
| Becky Mann | Licensing Program Analyst | Conducted the complaint investigation |
| Sam Goings | Director of Operations | Met with investigators during the visit |
| Lisa Leak | Administrator | Facility administrator mentioned in the report |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 64
Deficiencies: 1
Date: Sep 20, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to safeguard resident's personal property as resident #1's dresser/mirror and night stand were documented missing.
Report Facts
Capacity: 64
Census: 30
Plan of Correction Due Date: Sep 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Magda Malcore | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jessica Ramos | Facility administrator met during the investigation and exit interview | |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 64
Deficiencies: 0
Date: Mar 25, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation of illegal eviction of a resident from the facility.
Complaint Details
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.
Findings
The investigation found insufficient evidence to substantiate the allegation of illegal eviction; therefore, the complaint was determined to be unsubstantiated.
Report Facts
Capacity: 64
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Magda Malcore | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jessica Ramos | LVN | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 64
Deficiencies: 0
Date: Feb 26, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff were not providing residents their medications as prescribed.
Complaint Details
The complaint alleged that staff were intentionally not providing residents their medications as prescribed. The allegation was found to be unsubstantiated.
Findings
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.
Report Facts
Staff interviewed: 6
Residents interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Magda Malcore | Licensing Program Analyst | Conducted the complaint investigation |
| Jessica Ramos | LVN | Met with investigator during complaint investigation |
| Lisa Leak | Administrator | Facility administrator |
| Karen Clemons | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 50
Capacity: 64
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
Licensing Program Analyst Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection.
Findings
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).
Deficiencies (1)
The facility did not maintain a health screening with tuberculosis results for staff #1 (S1), which poses a potential health, safety or personal rights risk to persons in care.
Report Facts
Capacity: 64
Census: 50
Plan of Correction Due Date: Feb 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Magda Malcore | Licensing Program Analyst | Conducted the inspection and cited the deficiency |
| Karen Clemons | Licensing Program Manager | Supervisor overseeing the inspection |
| Jaclyn Nava | Administrator | Facility administrator met during inspection |
Inspection Report
Follow-Up
Census: 50
Capacity: 64
Deficiencies: 0
Date: Jan 8, 2024
Visit Reason
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.
Findings
No deficiencies were cited during this visit. The Licensing Program Analyst obtained documentation and conducted interviews with residents and staff involved in the incident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaclyn Nava | Administrator | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit. |
| Magda Malcore | Licensing Program Analyst | Conducted the unannounced case management visit and interviews. |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 50
Capacity: 64
Deficiencies: 1
Date: Nov 17, 2023
Visit Reason
Licensing Program Analyst Magda Malcore made an unannounced visit to conduct a Health and Safety check to the facility.
Findings
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.
Deficiencies (1)
Administrator Nava did not have an Administrator Certification, which poses a potential health, safety, and personal rights risk to persons in care.
Report Facts
Capacity: 64
Census: 50
Plan of Correction Due Date: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaclyn Nava | Administrator | Named in deficiency for lacking Administrator Certification |
| Magda Malcore | Licensing Program Analyst | Conducted the inspection visit |
| Karen Clemons | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
The visit was conducted to initiate a complaint investigation related to the facility, identified by Complaint Control Number 56-AS-20230710091048.
Complaint Details
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and returned to the facility to make corrections to the original report. |
| Lisa Leak | Administrator | Met with the Licensing Program Analyst during the visit and participated in the exit interview. |
| Karen Clemons | Licensing Program Manager | Named in the report as the Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 64
Deficiencies: 0
Date: Jul 13, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations including facility disrepair, residents wearing dirty clothing, and poor food quality.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
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.
Report Facts
Facility capacity: 64
Census: 46
Number of residents interviewed: 5
Number of staff interviewed: 4
Number of outside parties interviewed: 1
Non-perishable food supply: 7
Perishable food supply: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Lisa Leak | Administrator | Facility administrator met during investigation and exit interview |
| Tiurma Sihotang | Assistant Administrator | Met during investigation and informed of visit |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 64
Deficiencies: 1
Date: Aug 10, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Personnel did not have adequate training or related experience to safely assist with prescribed medications which are self-administered, resulting in medication not being safely dispensed to the correct resident.
Report Facts
Deficiencies cited: 1
Residents present: 45
Total licensed capacity: 64
Staff present: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation. |
| Katrina Wharton | Caregiver | Interviewed during the investigation and involved in the exit interview. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 64
Deficiencies: 0
Date: Jun 16, 2022
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that a resident did not get dinner.
Complaint Details
The complaint alleging a resident did not get dinner was investigated and found to be unsubstantiated due to lack of evidence.
Findings
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.
Report Facts
Staff present: 7
Residents interviewed: 7
Staff interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Gardner | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Leak | Administrator | Facility administrator met during the investigation |
| Karen Clemons | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 64
Deficiencies: 1
Date: Jun 7, 2022
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff were not providing a resident with diapers.
Complaint Details
The complaint was substantiated based on interviews and record review. The allegation that staff were not providing the resident with diapers was found valid.
Findings
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.
Deficiencies (1)
The licensee knowingly provided pull-up diapers that did not fit the resident, causing pain and failing to manage incontinent care correctly, posing an immediate health, safety, or personal rights risk.
Report Facts
Number of residents present: 49
Total licensed capacity: 64
Number of staff present: 7
Number of deficiency cited: 1
Number of packs of correct size diapers delivered: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Leak | Administrator | Named in findings related to diaper provision and interview |
| Ryan Gardner | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Karen Clemons | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 64
Deficiencies: 0
Date: Mar 1, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Javier Prieto | Licensing Program Analyst | Conducted the complaint investigation. |
| Lisa Leak | Administrator | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Annual Inspection
Census: 37
Capacity: 64
Deficiencies: 0
Date: Jan 27, 2022
Visit Reason
Licensing Program Analyst Javier Prieto made an unannounced visit to conduct an annual inspection with an emphasis on infection control.
Findings
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.
Report Facts
COVID-19 cases: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Leak | Administrator | Met with Licensing Program Analyst during the inspection. |
| Javier Prieto | Licensing Program Analyst | Conducted the annual inspection. |
| Karen Clemons | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 64
Deficiencies: 1
Date: Nov 10, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility staff did not give topical treatment medication as prescribed for Resident 1, posing a potential health, safety, and personal rights risk.
Report Facts
Capacity: 64
Census: 41
Plan of Correction Due Date: Nov 17, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Semin | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lisa Leak | Administrator | Facility administrator met during investigation and named in findings |
| Karen Clemons | Licensing Program Manager | Named in report as Licensing Program Manager |
Report
January 23, 2026
Report
September 16, 2025
Report
May 6, 2025
Report
Jan 16, 2025
Report
Jan 16, 2025
Report
Dec 12, 2024
Report
Sep 5, 2024
Report
May 3, 2024
Report
Dec 19, 2023
Report
November 17, 2023
Report
Nov 4, 2023
Report
Sep 29, 2023
Report
Sep 24, 2023
Report
Sep 10, 2023
Report
Jul 15, 2022
Report
Nov 25, 2019
Viewing
Loading inspection reports...
