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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607590
Report Date: 11/18/2022
Date Signed: 11/18/2022 02:07:07 PM


Document Has Been Signed on 11/18/2022 02:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:HERITAGE HOME CAREFACILITY NUMBER:
197607590
ADMINISTRATOR:NINO S. NAVARROFACILITY TYPE:
740
ADDRESS:4146 ATLANTIC CIRCLETELEPHONE:
(626) 272-1540
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:6CENSUS: 6DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Administrator, Michelle NavarroTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Annual Required / Infection Control visit to the above facility. LPA was met by Caregivers, Lorna Alcantara and Jojo Aguilar. LPA was screened for Covid-19 including temperature check and asked to sign in the guest book by caregiver Jojo Aguilar and the purpose of today’s visit was explained. Administrator, Michelle Navarro arrived at 12:35pm and assisted LPA with the inspection. There are currently six (6) residents in the facility, (3) of which are hospice. The facility is licensed to serve elderly residents, all rooms are cleared for non-ambulatory residents. Hospice waiver approved for three (3) out of six (6) residents. LPA and Administrator inspected the entire facility inside and out. The facility is a single-story home located in a residential neighborhood, (6) bedrooms, (3) bathrooms, living room, family room, dining room, kitchen, attached garage/activity area, laundry area, backyard, covered patio area.

At 12:45pm, LPA and the Administrator toured the facility. The following was observed/inspected:
  • The facility had a universal entrance screening area; sign-in and temperature logs were maintained.
  • COVID-19 signage was placed in several areas of the facility including the front entrance.
  • All areas were found to be clean and in good repair.
  • Facility maintained a 30-day supply of PPE to include masks, gowns, and face shields, all stored in the garage area.
  • Staff wore face masks consistently throughout the shift.
  • All resident bedrooms were toured. Each room contained required furniture including bed, dresser, nightstand, lamp, chair, and closet.
  • All beds contained the required linens including mattress cover, fitted sheet, flat sheet, blanket, and comforter.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HERITAGE HOME CARE
FACILITY NUMBER: 197607590
VISIT DATE: 11/18/2022
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  • Bathrooms are clean and operational and were observed to be within Title 22 regulations. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Bathrooms contained supplies including liquid soap, toilet paper, and paper towels.
  • At 12:50pm, hot water temperature was checked and read 112.7 deg. F in the kitchen sink, bathroom #1 118.9 deg. F, in bathroom #2, 118.2 deg. F in bathroom #3 and 118.6 deg. F, all are within the required 105.120 degrees.
  • Kitchen was inspected and LPA observed sufficient perishable and non-perishable food. All the appliances are clean and are operating properly. There is a 2nd freezer in the garage/activity area with additional food supplies.
  • Knives and other sharp items are stored and locked in a kitchen cabinet which are inaccessible to residents.
  • Hazardous toxins, dishwashing soap and/or other cleaning items are also locked under the kitchen sink and inaccessible to residents.
  • Laundry room is located inside the garage and there are cabinets with locks where they store the PPE supplies.
  • Some hazardous cleaning supplies and laundry detergents are also stored in the locked cabinets in the garage and inaccessible to residents.
  • Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards.
  • A shaded area with chairs is provided for residents in the patio area. The facility is in good repair and Facility temperature was comfortable and read at 75 deg. F.
  • First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present.
  • All residents' medications were reviewed, and LPA observed that medications are stored, locked in one of the kitchen cabinets and inaccessible to residents. Medications are documented properly and given as prescribed.
  • All Staff and residents are fully vaccinated with booster shots.
  • Smoke detectors/carbon monoxide detectors, auditory device in the bedrooms were present and operable.
  • Two (2) fire extinguishers were observed to be new and fully charged. One (1) is in the kitchen/dining area and the other one is in the garage/activity area.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. An exit interview was held, and a copy of the report was provided to Administrator, Michelle Navarro.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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