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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600455
Report Date: 05/16/2022
Date Signed: 05/17/2022 11:40:49 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2022 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20220513121113
FACILITY NAME:HERITAGE BOARD & CARE #4FACILITY NUMBER:
198600455
ADMINISTRATOR:WARREN TRINIDADFACILITY TYPE:
735
ADDRESS:1509 EAST 4TH STREETTELEPHONE:
(562) 437-2070
CITY:LONG BEACHSTATE: CAZIP CODE:
90802
CAPACITY:20CENSUS: 13DATE:
05/16/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:LICENSEE MARY TRINIDADTIME COMPLETED:
10:36 AM
ALLEGATION(S):
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Facility backyard is in disrepair(waste water)
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility on 05/16/2022 at 09:00 AM and was greeted by Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10 day visit on 05/16/2022 approximately 09:00 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 05/16/2022 LPA Calderon requested copies of the following: Pest control records for complaint. On 05/16/2022 LPA Calderon interviewed S1 for complaint and on 05/16/2022 LPA Calderon interviewed R1 – R6 for complaint. On 05/16/2022 LPA Calderon interviewed W1 for complaint.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20220513121113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HERITAGE BOARD & CARE #4
FACILITY NUMBER: 198600455
VISIT DATE: 05/16/2022
NARRATIVE
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Regarding Allegation #1: Facility backyard is in disrepair. On 05/16/2022 LPA Calderon interviewed W1 who stated that the facility dumps dirty waste water in the back alley. On 05/16/2022 LPA Calderon interviewed S1 who states that her staff does dump dirty waste water in the back alley as W1 states. On 05/16/2022 LPA Calderon interview R1 – R6 who state they have not seen facility staff dumping dirty waste water in the back-yard area.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of FACILITY BACKYARD IS IN DISREPAIR while in care is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1,6, the following deficiency had been observed and a citation issued (ref. LIC 9099D).

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator (Mary Grace Trinidad).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220513121113
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE BOARD & CARE #4
FACILITY NUMBER: 198600455
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights(a)Except for children’s residential facilities....(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. The requirement is not met as evidenced by:
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Licensee to train staff in the proper disposile of watewater by 05/20/2022.Train staff to dispose of watewater properly.
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Based on interviews and observations and record review the licensee did not ensure that the waterwater was disposed properly which poses a potential health 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3