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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200506
Report Date: 04/28/2026
Date Signed: 04/28/2026 11:34:23 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2026 and conducted by Evaluator Yasamin Brown
COMPLAINT CONTROL NUMBER: 15-AS-20260325162814
FACILITY NAME:HERITAGE HAVENFACILITY NUMBER:
019200506
ADMINISTRATOR:FERDINAND GUTIERREZFACILITY TYPE:
740
ADDRESS:389 JUANA AVENUETELEPHONE:
(510) 357-1300
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:27CENSUS: 19DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ferdinand Gutierrez, Administrator TIME COMPLETED:
11:50 PM
ALLEGATION(S):
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Facility not following reporting requirements
INVESTIGATION FINDINGS:
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On 4/28/2026 at 11:00 am, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Ferdinand Gutierrez, Administrator and explained the purpose of the visit.

During the course of investigation, LPA obtained the following documents for R1 and R2: LIC602 (Medical Assessment), Identification and Emergency Contact, and Appraisal Needs and Services Plan. LPA obtained the following documents: Resident Roster and the LIC500 (Personnel Report) and R2's police report. LPA also conducted interviews with S1, S2, and S3.

Continue on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20260325162814
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HERITAGE HAVEN
FACILITY NUMBER: 019200506
VISIT DATE: 04/28/2026
NARRATIVE
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Continued from LIC9099.

Allegation: Facility not following reporting requirements

Finding: Substantiated


During interview and record review, LPA discovered that on 3/18/2026, the police conducted a visit at the facility to speak with R1 regarding R1's behavior at the facility. S1 stated that R1 was working with their case manager and now has been moved to a different facility. LPA reviewed an incident report regarding the situation that was sent to CCLD on 3/27/2026. Interviews with S1, S2, and S3 revealed that there were no other incident reports submitted to CCLD regarding the situation.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC9099D.

Exit interview was conducted with Ferdinand, appeal rights and a copy of this report was provided.


SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2026 and conducted by Evaluator Yasamin Brown
COMPLAINT CONTROL NUMBER: 15-AS-20260325162814

FACILITY NAME:HERITAGE HAVENFACILITY NUMBER:
019200506
ADMINISTRATOR:FERDINAND GUTIERREZFACILITY TYPE:
740
ADDRESS:389 JUANA AVENUETELEPHONE:
(510) 357-1300
CITY:SAN LEANDROSTATE:CAZIP CODE:
94577
CAPACITY:27CENSUS: 19DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ferdinand Gutierrez, Administrator TIME COMPLETED:
11:50 PM
ALLEGATION(S):
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2
3
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5
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8
9
Residents personal rights are being violated
INVESTIGATION FINDINGS:
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On 4/28/2026 at 11:00 am, Licensing Program Analyst (LPA) Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Ferdinand Gutierrez, Administrator and explained the purpose of the visit.

During the course of investigation, LPA obtained the following documents for R1 and R2: LIC602 (Medical Assessment), Identification and Emergency Contact, and Appraisal Needs and Services Plan. LPA obtained the following documents: Resident Roster and the LIC500 (Personnel Report) and R2's police report. LPA also conducted interviews with S1, S2, and S3.

Continue on LIC9099-C.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20260325162814
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HERITAGE HAVEN
FACILITY NUMBER: 019200506
VISIT DATE: 04/28/2026
NARRATIVE
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Continued from LIC9099.

Allegation: Residents personal rights are being violated

Finding: Unsubstantiated

During interview and record review, LPA discovered that on 3/18/2026, the police conducted a visit at the facility to speak with R1 regarding R1's behavior at the facility. S1 stated that they have been working with R1's case manager about R1's increased behaviors. Interviews with S1, S2, and S3 revealed that R1 has been showing behaviors towards R2 such as yelling, screaming, and banging on the wall. Staff interviews revealed that R1 and R2 never had a physical or verbal altercation but R1 was displaying those behaviors towards R2 at the facility. S1 stated that R1 has now been moved to a different facility by their case manager.



Based on interviews and record review during visit, the allegation that Residents personal rights are being violated was found to be unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.



Exit Interview conducted with Ferdinand and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20260325162814
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HERITAGE HAVEN
FACILITY NUMBER: 019200506
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2026
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...
This requirement is not met as evidenced by:
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By POC date, the Administrator agrees to complete an all staff in-service retraining on reporting requirements and compliance with section 87211 and send proof of the in-service to CCLD.
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Based on record review and interview, the licensee did not comply with the section cited above in that an incident report was submitted 9 days after the incident occurred which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5