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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600455
Report Date: 06/07/2024
Date Signed: 06/07/2024 11:32:12 AM

Document Has Been Signed on 06/07/2024 11:32 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:		WARREN TRINIDADFACILITY TYPE:
735
ADDRESS:1509 EAST 4TH STREETTELEPHONE:
(562) 900-6257
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY: 20CENSUS: 11DATE:
06/07/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:LILIA BALIWAGTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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06/07/2024 an office meeting was conducted by the El Segundo Adult and Senior Care Program, present during the meeting were Regional Manager Araceli Ramirez, Licensing Program Manager (LPM) Janae Hammond, LPM Ulysses Coronel, Licensing Program Analyst (LPA) Jose Calderon, Licensee Lilia Baliwag and Administrator Mary Cruz. The purpose of this meeting is to document deficiencies observed during Trust Audit conducted by CCLD. The Trust Audit revealed the following: Clients C1-C14 have been financially abused. The licensee did not maintain a surety Bond. The clients cash resources were comingled with facility expenses. And that the licensee did not provide general supervision over the affairs of the facility, that resulted to clients being financially abused by administrative staff S1, S2 and S3. California Code of Regulations, Title 22, Division 6 Chapter 1 are being cited on the attached LIC 809D.

An exit interview was conducted, appeals rights and a copy of this report was provided to licensee Lilia Baliwag for review and signature.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document is an Amendment of Original Document on 12/03/2025 01:45 PM


Created By: Jose Calderon On 06/07/2024 at 09:42 AM
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
EL SEGUNDO ASC, 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: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2024
Section Cited
CCR
80026(h)(1)(A-C)

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Safeguards for Cash Resources, Personal Property, and Valuables of Residents. Each licensee shall maintain accurate records…following: Records … shall be filed in chronological order. Receipts … shall include the client's full signature or mark…(payor)…The…client. This requirement was not met as evidenced by:
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The licensee will develop a plan outlining the steps the Licensee plans to take to ensure that P&I funds which total to $51,764.00 are returned to clients C1-C11. Proof of corrections will be submitted by the POC due date.

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Based on trust audit the licensee did not maintain accurate records of client’s cash resources for the period from 01/01/2021 to 07/31/2023 and owed clients C1-C11 their P&I funds. Which poses a potential health, safety, and personal rights risk to clients in care.
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Type B
07/08/2024
Section Cited
CCR80025(c)

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Bonding. This requirement was not met as The amount of the bond shall be according to the following schedule:
AMOUNT SAFEGUARDED PER MONTH BOND REQUIRED
750 or less $1,000
$751 to $1,500 $2,000
$1,501 to $2,500 $3,000
very further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond. This requirement was not met as evidenced by:
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The licensee will submit a copy of bond issued by a surety company to the State of California as principal in accordance with 80025(C). Proof of correction will be submitted by email by the POC due date.

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Based on records reviews the licensee did not ensure that a bond showing the specific coverage amount was filed with the department which posed a potential health and safety risk to residents in care.
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Jose Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 06/07/2024 11:32 AM - It Cannot Be Edited


Created By: Jose Calderon On 06/07/2024 at 09:44 AM
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: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2024
Section Cited
CCR
80026(e-i)

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Safeguards for Cash Resources, Personal Property, and Valuables of Residents.
Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash. Immediately upon admission of a client, all his/her cash resources entrusted to the licensee and not kept in the licensed facility shall be deposited in any type of bank, savings and loan, or credit union account meeting the following requirements: This requirement was not met as evidenced by:

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The licensee will develop a plan outlining the steps the licensee will take to ensure that clients’ P&I funds are not co-mingled with the facilities’ business operating funds. Proof of correction will be submitted by email by the POC due date.

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Based on records reviews the licensee comingled clients’ P&I funds with facilities’ business operating funds which poses a potential health and safety risk to residents in care.

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Type B
07/08/2024
Section Cited
CCR80063(a)

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Accountability. The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation. This requirement was not met as evidenced by:

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The licensee will develop a plan outlining the general supervision and policies established to ensure compliance with Title 22 Regulations 80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents and 80025 Bonding. Plan of correction will be submitted by email by the POC due date.

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Based on records reviews the licensee failed to supervise the licensed facility and establish policies concerning its operation that resulted to clients being financially abused, which poses a potential health and safety risk to residents in care.

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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Jose Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
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