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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600455
Report Date: 09/26/2024
Date Signed: 09/27/2024 10:54:53 AM

Document Has Been Signed on 09/27/2024 10:54 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, 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:
09/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Danilo Garcia, HousekeeperTIME VISIT/
INSPECTION COMPLETED:
08:45 AM
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On Thursday, September 26, 2024 at 8:20am LPA Zina Brown made an unannounced visit to facility to amend the report from Wednesday, September 25, 2024. No deficiencies cited were cited during today.

Exit interview was conducted with Danilo Garcia and a copy of the report with appeal rights.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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