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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600455
Report Date: 02/01/2022
Date Signed: 02/01/2022 03:41:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2022 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20220127115823
FACILITY NAME:HERITAGE BOARD & CARE #4FACILITY NUMBER:
198600455
ADMINISTRATOR:WARREN TRINIDADFACILITY TYPE:
735
ADDRESS:1509 EAST 4TH STREETTELEPHONE:
(562) 437-2070
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:20CENSUS: 14DATE:
02/01/2022
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Mary Grace TrinandadTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident injured another resident
INVESTIGATION FINDINGS:
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On 02/01/22 Licensing Program Analyst (LPA) Jade Jordan Conducted an unannounced complaint visit,
Regarding the allegation above. LPA was met by Administrator Mary Grace Trinidad, and staff.
The purpose of the visit was explained.

The investigation Consisted of: Staff Interviews, Resident interviews, Record Review, and pertinent documents (Physician Report, Needs Service Plan, Medical Records) pertaining to the complaint.

Regarding Allegation: “Resident injured another resident”
Interviews with Reporting Party (RP) stated that they overheard Resident (R1) on 01/25/22 telling a liquor store owner that they were caused injury by another resident in care. During the complaint intake, RP was unable to state who the abuser was, or the name of the resident in question. During LPA interview RP stated that they did not physically see resident being assaulted. Interviews conducted with staff (S1, S2) revealed that R1 actually assaulted staff (S1) , and have a Resident witness. Staff 2 stated that they were mopping the other side of the facility and heard Staff screaming for help. S2 stated that they saw R1 standing over S1 with a stick and yelled for R1 to stop.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
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 2
Control Number 11-AS-20220127115823
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HERITAGE BOARD & CARE #4
FACILITY NUMBER: 198600455
VISIT DATE: 02/01/2022
NARRATIVE
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 Interviews with Resident 2 (R2), revealed that they also saw S1 on the floor screaming with R1 standing over them with a stick. The police were called, and R1 was taken into a 51/50 hold at the hospital. Interviews with other residents in care (R2-R5) revealed, that they have not seen any Staff causing injury to residents in care, nor have they witnessed any Resident causing injury to other residents in care. Interviews with Staff 1, and 2 revealed that they have not hit any resident in care, nor have they witnessed any resident hit another resident.

Based on Interview, Record Review, and observation the LPA finds that: Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.


An Exit interview was conducted and a copy of this report was provided. No citations were issued during this visit.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2