198600455-10-31-2023-11-AS-JCAN-CWYP8Z-20231026110621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600455
Report Date: 10/26/2023
Date Signed: 10/31/2023 09:36:50 AM

Document Has Been Signed on 10/31/2023 09:36 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	HERITAGE BOARD & CARE #4		FACILITY NUMBER:	198600455
ADMINISTRATOR:	WARREN TRINIDAD		FACILITY TYPE:	735
ADDRESS:	1509 EAST 4TH STREET		TELEPHONE:	(562) 900-6257
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY: 20		CENSUS: 18	DATE:	10/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	ADMINISTRATOR MARY TRINIDAD		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/26/2023 at 09:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Facility Heritage Board & Care #4. LPA Calderon was allowed entry into the facility by Administrator Mary Trinidad. LPA Calderon asked infection control questions and Administrator Mary Trinidad took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for twenty (20) developmentally disabled adult clients. Currently, there are (18) residents residing in the facility with developmentally disabled issues. LPA Calderon explained to Administrator Mary Trinidad, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: (3) resident service records, (3) resident medication records, (3) staff records. LPA Calderon interviewed (3) residents and (3) staff members for visit. The facilities’ last fire drill was conducted on 08/14/2022. The one-story building consists of (10) resident bedrooms, (4) resident bathrooms, meeting area, dining room, kitchen, staff room, office area, storage area, washer and dryer room, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the storage room.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE BOARD & CARE #4	FACILITY NUMBER: 198600455
	VISIT DATE: 10/26/2023

NARRATIVE

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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms 3, 6, 8, 10: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 110 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit. Bathroom #3 hot water temperature properly measured at 108 degrees Fahrenheit, and bathroom #4 hot water temperature properly measured at 117 degrees Fahrenheit Kitchen hot water temperature properly measured at 112 degrees Fahrenheit. Facility (4) Carbon Monoxide and (20) Smoke Detectors hard wired and connected were tested and are working properly. The facility (3) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water or trash were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents and there is inside and outside seating. Three (3) resident files were reviewed and found to be complete. LPA Calderon reviewed (3) resident medications and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. LPA Calderon noted the Licensee Lilia P Balwag Certification # 6010204735 expiration date of 02/14/2024 was valid at time of visit. The facility does handle resident's money/cash resources and a Surety bond #RSB0594591 from RLI Insurance Company for $5,000.00 expires on 08/08/2024 was noted by LPA Calderon. General Liability Policy #ACP GLO 3029967190 policy period from 11/21/2022 to 11/21/2023 underwritten by Nationwide Mutual Insurance Company Inc, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Mary Trinidad who will email copy insurance contact to LPA Calderon no later than 12/01/2023. All the required documents are posted in the facility in a clearly visible area.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE BOARD & CARE #4	FACILITY NUMBER: 198600455
	VISIT DATE: 10/26/2023

NARRATIVE

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During the visit, LPA Calderon observed the facility infection control practices. LPA Calderon observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and residents were NOT wearing face coverings, an isolation room and required postings throughout the facility. LPA Calderon observed the facility has a thirty-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Mary Trinidad to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Mary Trinidad.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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