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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600455
Report Date: 03/04/2024
Date Signed: 03/04/2024 03:44:28 PM

Document Has Been Signed on 03/04/2024 03:44 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:HERITAGE BOARD & CARE #4FACILITY NUMBER:
198600455
ADMINISTRATOR:WARREN TRINIDADFACILITY TYPE:
735
ADDRESS:1509 EAST 4TH STREETTELEPHONE:
(562) 900-6257
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY: 20CENSUS: 12DATE:
03/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:ADMINISTRATOR MARY CRUZTIME COMPLETED:
04:00 PM
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On 03/04/2024 around 02:00PM Licensing Program Analyst (LPA) Jose Calderon initiated an unannounced Case Management visit - Other to provide Technical Assistance to the above said facility Heritage Board and Care 4. Today’s visit was conducted face to face with Administrator Mary Cruz (A1).

LPA Calderon tour consisted of a single-story commercial building, all common areas which included but were not limited to building entrances, reception areas, office, hallways, restrooms, dining room, kitchen, pantry, medication storage area. LPA Calderon also reviewed the facility's entry procedures, body temperature monitoring practices, social distancing practices, protective facial covering practices and disinfection/sanitation practices with A1.

The LPA Calderon also requested copies of the following: facility's records which include but are not limited to copy of C1-C2 facility file, incident report (date 03/02/2024) staff and client rosters, Admission agreement for C1-C2. On 03/04/2024 LPA Calderon interviewed Administrator (A1) who states that she was advised of the allegation of a drug overdose by C1-C2 on 03/02/2024. A1 states that the supposed drug overdose happened around 3:40pm in room #5. A1 states that Long Beach Police and Fire departments arrived and closed room #5 due to possible fentanyl substance in the room. A1 states that the police report number is #DR2410972. A1 states that that the coroner arrived and took the bodies to the morgue. A1 states that house manager Danny Garcia found the bodies in room #5 with the door closed. A1 can not confirm a drug overdose at this time, but the police stated that most likely the 2 clients did overdose on drugs as a drug pipe was found in the room. A1 states that C1 may have had used drugs in the past. A1 states that she did inform C1 and C2 family of the passing of their family members. A1 states that Ida Gervicio staff and Danny Garcia house manager were working at time of incident. A1 states that she is unsure which clients were in the facility on 03/04/2024.

An exit interview was conducted with Administrator Mary Cruz (A1) and a hard copy was provided via email for signature.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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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