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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600455
Report Date: 10/06/2021
Date Signed: 10/06/2021 03:21:21 PM

Document Has Been Signed on 10/06/2021 03:21 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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: 16DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Warren TrinidadTIME COMPLETED:
03:30 PM
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On 10/06/21 Licensing Program Analyst (LPA) Jade Jordan Arrived to conduct an unannounced Annual Inspection, with an emphasis on Infection Control. LPA confirmed by Telephone with Administrator Warren
Trinidad, that there were no Positive Covid -19 Cases within the facility. Upon entry the purpose of the visit
was explained. LPA Observed Required Posting, including hand washing Hygiene, and was screened for temperature, by Staff Danny. LPA was later met by Administrator Mary Grace Trinidad, who assisted in giving a physical plant tour. This facility is licensed to serve (20) Ambulatory, Mentally Disabled Adults ages 18- 59.

The facility has 10 shared client rooms, two unisex client bathrooms, one shared private bathroom in room 8,9, and one designated staff bathroom located near storage. The 3 client bathroom which have 3 toilets, 3 sinks, and 3 showers. The toilets have doors for privacy, and the showers have curtains for privacy. During the tour, LPA Jordan observed client bedrooms, there is one vacancy. Each bed has all required linen, the rooms have sufficient closet & drawer space, there are chairs available in the rooms, and the smoke detectors are functioning properly. Last fire drill conducted in July of 21. LPA toured the outside yard area, and there are no hazardous items in the yard. There is a front porch with chairs where clients may sit and smoke or relax. The washer & dryer are in the laundry room in the hall, and laundry supplies are also kept in the locked laundry room. There is a 7 day supply of non-perishable foods, and a 2 day supply of perishable foods in the kitchen. An additional supply of perishable and non-perishable food in the storage, and in commercial size freezer. Sharp knives are locked in the kitchen. Toxic cleaning agents are locked under the sink in the kitchen.

Medications were observed locked in a cart in the kitchen. LPA reviewed the client medications & the medication log book, client files, and staff files.





SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HERITAGE BOARD & CARE #4
FACILITY NUMBER: 198600455
VISIT DATE: 10/06/2021
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During the visit Lpa observed infection control practices. Staff were observed wearing masks, and reminding clients to wear masks. LPA observed a 30 day supply of PPE ( gloves, masks, gowns, N95's, faceshields).

The Administrator explained her plan to LPA, regarding isolating the clients who may come in contact with covid-19. LPA Advised that designated isolation room if Covid -19 were to arise, should be the bedroom with private bathroom, to avoid cross contamination in the facility.

The front entrance wall was observed to have a light puncture from a chair, Technical advisory was given for minor aesthetic's through out the facility.

An Exit interview was conducted, and a copy of this report was provided.
No deficiency's were cited during this visit.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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