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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600455
Report Date: 09/25/2024
Date Signed: 09/25/2024 02:36:26 PM

Document Has Been Signed on 09/25/2024 02:36 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/
DIRECTOR:		MARILEE CRUZFACILITY TYPE:
735
ADDRESS:1509 EAST 4TH STREETTELEPHONE:
(562) 900-6257
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY: 20CENSUS: DATE:
09/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Mary Cruz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 09/25/2024 at 8:40am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Mary Cruz, Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (20) ambulatory, (0) non-ambulatory, (0) bedridden developmentally disabled adults ages 18 through 59. Currently, the home has (16) clients. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The annual facility fee renewal is a balance of $0. Liability Insurance Policy is current and valid from 11/21/2023 - 11/21/2024.

The facility is a one story home located in a residential neighborhood. The property consists of the following: 10 resident bedrooms, 4 common bathrooms, staff office, living room, storage room, kitchen, pantry room, dining room, a linen closet, a laundry room with a washer and a dryer, and backyard and an outdoor shaded area in the front of the facility.

LPA conducted a records review of (8) client records, (5) staff records, (8) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & Staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (4) Client Medication Administration Records and did not observed any discrepancies at the time of visit.

Report continue on LIC-809C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #4
FACILITY NUMBER: 198600455
VISIT DATE: 09/25/2024
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At 8:50am LPA Zina Brown and Danilo Garcia, housekeeper toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured over 105-120F ( Bathroom #1- 140.3F, Bathroom #2 - 142.7, and kitchen at 142.6 F)

Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were tested by the fire department, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During todays visit LPA did observe deficiencies such

  • water temperature in bathroom # 1 and bathroom #2 exceeding 120.0. F pass the Title 22 regulation guidelines.
  • Staff #5 was not associate to this facility (LIC 9182) at the date and time LPA conducted unannounced visit.
  • LPA identified and observed exterior gates has padlocks.

Deficiencies sited under California Code of Regulations Title 22, Division 6, Chapter 1 & 6.

Exit interview conducted with Mary Cruz and a copy of the report, and was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/25/2024 02:36 PM - It Cannot Be Edited


Created By: Zina Brown On 09/25/2024 at 01:51 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HERITAGE BOARD & CARE #4
FACILITY NUMBER: 198600455

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(2)
Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f);

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, staff Jomar Tandoa was not associated to the facility as the time of unannouced inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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The facility shall associate staff in Guardian and submit proof of update via email zina.brown@dss.ca.gov by POC due date.
Type A
Section Cited
CCR
80088(e)(1)
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the water temperature in bathroom #1 tested at 140.3 F, bathroom #3 tested at 142.7 F, and the kitchen sink tested at 142.6 F licensee did not comply with the section cited above in which poses an immediate health and safety rights to clients in care
POC Due Date: 09/26/2024
Plan of Correction
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The licensee the will lower the water heater and continue to test the water temperature in all bathrooms and kitchen for next 24 hours. The licensee will self-certify the water temperature is within required range of 105F - 120F.
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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/25/2024 02:36 PM - It Cannot Be Edited


Created By: Zina Brown On 09/25/2024 at 02:02 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HERITAGE BOARD & CARE #4
FACILITY NUMBER: 198600455

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(7)(A)
(a)each client shall have personal rights which include, but are not limited to, the following:
Not to be locked in any room, building, or facility premises by day or night.
(A) The licensee shall not be prohibited by this provision from locking exterior doors and windows or from establishing house rules for the protection of clients provided the clients are able to exit the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the facility did not comply with the section cited above. LPAs observed two (2) exterior front and back gate on the side had padlocks in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2024
Plan of Correction
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Licensee will adhere to Title 22 Regulation 80072(a)(7)(a) and remove padlocks from front and back gate exterior or notify licensing agency for an exemption to maintain gate locks. Proof of correction (photo) must be sent to zina.brown@dss.ca.gov within 24 hours of POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


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