<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600456
Report Date: 11/02/2023
Date Signed: 11/03/2023 08:25:24 AM

Document Has Been Signed on 11/03/2023 08:25 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:HERITAGE BOARD & CARE #2FACILITY NUMBER:
198600456
ADMINISTRATOR:MARY GRACE TRINIDADFACILITY TYPE:
735
ADDRESS:2445 PACIFIC AVENUETELEPHONE:
(562) 900-6334
CITY:LONG BEACHSTATE: CAZIP CODE:
90806
CAPACITY: 18CENSUS: 18DATE:
11/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:House manager Policronio Domingo Jr.TIME COMPLETED:
11:20 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/02/23, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with House manager Policronio Domingo Jr. and explained the purpose of today’s visit. The facility is licensed for 18 developmentally disabled adult clients, current census is 18.

The facility is a single-story structure located in a residential neighborhood and consists of the following: (11) client bedrooms, (2) client bathrooms, meeting area/ dining room, kitchen/medication room, 1 staff bedroom, 1 staff restroom, washer and dryer room, and a two sided shaded porch area.Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be stored and inaccessible to clients. There are no bodies of water nor firearms on the property, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 2 client records, and 2 medication administration record. No discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 10/05/23, 3 fire extinguisher fully charged, facility has 2 Carbon monoxide detectors and 20 smoke detectors that are hard wired and interconnected and are working properly. Long Beach fire department checked fire alarm on October 2023. Landline and surety bond observed.

During today’s visit no discrepancies were observed.

Exit interview conducted with House manager Policronio Domingo Jr., and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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 1