198600455-5-17-2022-11-AS-JHAD-CEXVZX-20220531165328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600455
Report Date: 05/16/2022
Date Signed: 05/17/2022 11:38:43 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-20220513091711

FACILITY NAME:	HERITAGE BOARD & CARE #4		FACILITY NUMBER:	198600455
ADMINISTRATOR:	WARREN TRINIDAD		FACILITY TYPE:	735
ADDRESS:	1509 EAST 4TH STREET		TELEPHONE:	(562) 437-2070
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	20	CENSUS:	DATE:	05/16/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:			TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Facility has pests

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 5

Control Number 11-AS-20220513091711

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 has pests. On 05/16/2022 LPA Calderon interviewed W1 who stated that she was told by prior resident that the facility had mice, ants, and bedbugs. On 05/16/2022 LPA Calderon interviewed S1 who states that the facility has bedbug issues, mice issues and ant problem. S1 states she hired pest control company to take care of pest problems for the facility. On 05/16/2022 LPA Calderon interview R1 – R6 who state there are bedbugs, ants, mouse issues in the facility. On 05/16/2022 LPA Calderon reviewed pest control records which support that facility has pest issues.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of FACILITY HAS PEST 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). Civil penalty assessed.

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 5

Control Number 11-AS-20220513091711

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 05/27/2022 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	80087 Buildings and Grounds(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.(1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee will provide LPA with pest control records to support that pest had been taken care of. Licensee will give LPA proof as of 05/27/2022
	8 9 10 11 12 13 14	Based on interviews, observations and record review the licensee did not ensure that the facility is free of bedbugs, ants, mice as reported to LPA on 05/16/2022 which posed a potential health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 5

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-20220513091711

FACILITY NAME:	HERITAGE BOARD & CARE #4		FACILITY NUMBER:	198600455
ADMINISTRATOR:	WARREN TRINIDAD		FACILITY TYPE:	735
ADDRESS:	1509 EAST 4TH STREET		TELEPHONE:	(562) 437-2070
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	20	CENSUS:	DATE:	05/16/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:			TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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9

Staff do not assist residents with bathing
Staff do not assist residents with personal care

INVESTIGATION FINDINGS:

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Unsubstantiated

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: 4 of 5

Control Number 11-AS-20220513091711

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: Staff do not assist residents with bathing. On 05/16/2022 LPA Calderon interviewed W1 who stated that W1 was told by prior resident that the facility did not give baths to residents in need. On 05/16/2022 LPA Calderon interviewed S1 who states that the facility provided showers or baths to residents who need help, but for the most part all residents take their own showers. 05/16/2022 LPA Calderon interview R1 – R6 who state that they take care of their own shower every day and have not have any issues with staff care.

Regarding Allegation #2: Staff do not assist residents with personal care. On 05/16/2022 LPA Calderon interviewed W1 who stated that she was told by prior resident that the facility did not take care of resident’s needs. On 05/16/2022 LPA Calderon interviewed S1 who states that the facility provides residents with personal care for cleaning clothes and other care needs. On 05/16/2022 LPA Calderon interview R1 – R6 who state that the caregivers take care of their needs and they have no issues with the facility.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of Staff do not assist residents with bathing and Staff do not assist residents with personal care is found to be UNSUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report was 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: 5 of 5