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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600052
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:53:45 PM

Document Has Been Signed on 10/19/2023 12:53 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:HERITAGE ADULT RESIDENTIAL KAREFACILITY NUMBER:
198600052
ADMINISTRATOR:ODUNOLA TAIWOFACILITY TYPE:
735
ADDRESS:640 WEST CALDWELL AVENUETELEPHONE:
(310) 763-2829
CITY:COMPTONSTATE: CAZIP CODE:
90220
CAPACITY: 6CENSUS: 4DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:52 AM
MET WITH:Glenn DemarestTIME COMPLETED:
01:15 PM
NARRATIVE
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On 10/19/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Annual required visit using the New Care Inspection Tools. LPA was met with Facility Manager Demarest Glenn, and the purpose of today’s visit was explained. The facility is licensed to serve 6 developmentally disabled clients (age 18-65+).

There are currently (4) South Central Regional Center clients in placement. All (4) clients are ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 3 bathrooms, family room/dining room, kitchen, living rooms, shaded area, indoor and outdoor activity area, laundry room and an attached garage.



LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured in bathroom #1 116. 1F, #2 111.1F and #3 double sinks were 111.4f A comfortable temperature is maintained in the facility.

LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is a enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HERITAGE ADULT RESIDENTIAL KARE
FACILITY NUMBER: 198600052
VISIT DATE: 10/19/2023
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During the visit, LPA observed sanitizing stations located in common areas. Residents were not in the home due to being at the day program. LPA observed posting. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

A deficiency was cited and Technical advice was issued during today's visit.

An exit interview held. A plan of correction was developed. A copy of this report and Appeal Rights were given to the Facility Manager, Glenn Demarest.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
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Document Has Been Signed on 10/19/2023 12:53 PM - It Cannot Be Edited


Created By: Antonine Richard On 10/19/2023 at 12:26 PM
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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE ADULT RESIDENTIAL KARE
FACILITY NUMBER: 198600052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above, that Resident Arthur Jenkins Needs and Services Plan was current and on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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The facility will submit a plan of correction showing that all residents have an updated of Needs and Services Plan that is current and on file. The plan of correction will be submitted to LPA by 10/26/2023 to Antonine.Richard@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Antonine Richard
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


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