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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600455
Report Date: 02/01/2022
Date Signed: 02/01/2022 03:36:36 PM

Document Has Been Signed on 02/01/2022 03:36 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: DATE:
02/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Mary Grace TrinidadTIME COMPLETED:
03:45 PM
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On 02/01/22 Licensing Program Analyst (LPA) Jade Jordan Conducted a Case Management
in conjuction to Complaint number 11-AS-20220127115823.

Interviews revealed that Staff was assaulted by resident in care on 01/28/22.
The resident was upset due to staff instructing resident not to smoke in their
room, and reminding of facility policy. Resident became agitated and attacked
the staff.

Interviews conducted with Residents in care revealed that Resident 2 physically saw
the resident( R1) standing over the staff. Another resident R3 stated that although
they did not come out of their room they heard the staff screaming for help. Staff 2 stated that they saw
the resident R1 standing over staff 1, and had a stick in hand.

This incident was reported, and LPA received an SIR regarding the matter.
This information has been addressed in the complaint number addressed above.

An exit interview was conducted, and a copy of this report was provided
to Administrator. No citation were issued during this visit.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2022
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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