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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608268
Report Date: 12/12/2022
Date Signed: 12/12/2022 11:27:07 AM

Document Has Been Signed on 12/12/2022 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HERITAGE SENIOR HOME CAREFACILITY NUMBER:
197608268
ADMINISTRATOR:NINO NAVARROFACILITY TYPE:
740
ADDRESS:820 GLENLEA STREETTELEPHONE:
(626) 272-1540
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 6CENSUS: 3DATE:
12/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Nino Navarro - Administrator TIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) conducted a case management visit during a complaint investigation visit due to observed deficiencies. LPA met with Nino Navarro administrator and explained the reason for the visit.

On 12/12/22 LPA Flores conducted a tour of the facility to conduct a health and safety check. During the tour LPA observed the kitchen area and observed the following; cleaning spray was observed on top of the window sill, upon LPA explaining the cleaning spray must be lock staff placed it in cabinet under the sink and did not lock the cabinet. LPA observed the a drawer with utensil and sharps (knives) were observed, drawer was unlock at the time of the visit. Caregiver stated to be using cleaning solution and sharps.

Deficiencies are noted on LIC 809D under Title 22 Regulations.

Exit interview was conducted with Nino Navarro administrator and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
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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Document Has Been Signed on 12/12/2022 11:27 AM - It Cannot Be Edited


Created By: Mary G Flores On 12/12/2022 at 10:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE SENIOR HOME CARE
FACILITY NUMBER: 197608268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2022
Section Cited

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87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidence by:
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Based on observation licensee did not ensure staff maintained cleaning supplies, and knives at all times which poses a immediate risk to the health, safety, or personal rights of the 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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
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