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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600459
Report Date: 03/27/2023
Date Signed: 03/27/2023 04:54:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
03/24/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230324120831
FACILITY NAME:HERITAGE BOARD & CARE #1FACILITY NUMBER:
198600459
ADMINISTRATOR:MARY GRACE TRINIDADFACILITY TYPE:
735
ADDRESS:2330 & 2340 EAST 15TH STREETTELEPHONE:
(562) 433-7314
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY:42CENSUS: 32DATE:
03/27/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Warren & Mary Grace TrinidadTIME COMPLETED:
03:59 PM
ALLEGATION(S):
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Staff abandoned client at hospital.
INVESTIGATION FINDINGS:
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On 03/27/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by Administrators Warren & Mary Grace Trinidad. LPA explained the purpose of the visit is to investigate the allegation mentioned above.

The investigation revealed the following: The complainant requested an investigation concerning client #1 (C1). LPA obtained copies of the facility roster for residents and staff. Interviews conducted with staff #1-#2 (S1-S2) and witnesses #1 (W1). A reviewed of (C1)'s service records and other pertinent documents pertinent to the allegation on this complaint. A tour of the facility was performed.

(Evaluation Report continues on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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 4
Control Number 11-AS-20230324120831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HERITAGE BOARD & CARE #1
FACILITY NUMBER: 198600459
VISIT DATE: 03/27/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff abandoned client at hospital.
The details of the complaint reported client #1 (C1) was refused by staff to return to this facility. (C1) was admitted to St. Mary's Medical Center on 02/11/23 due to congestive heart failure. (C1) received medical attention and physical therapy (PT) while in care at the hospital and now is available for discharge. According to a witness #1 (W1), (C1) is ready to be discharged and was refused by the administrator staff #1 (S1) who cannot accept (C1) back at this facility as they have given (C1)'s bed away and that Social Security did not pay for his services. while (C1) in hospital for over 30-days. (W1) claimed that (C1) has maintained continuous physical therapy and is now considered ambulatory. Medical records stated (C1) is back at baseline and considered ambulatory and can walk 150 feet without a walker. An interview with administrators staff #1-#2 (S1-S2) reported that (C1) was admitted to the hospital due to an unwitnessed fall on 02/11/23 and not congestive heart failure. Due to the fall, (C1) suffered swollen and a wounded feet. On 03/15/23, staff #3 (S3) received a call from the hospital who stated (C1) is not ambulating and refusing to cooperate with (PT) and is still using a walker. The hospital was informed that (C1) is unable to return unless (C1) has fully recovered and is ambulatory. (S1-S2) claimed a follow-up call was received from the hospital on 03/16/23 that (C1) cannot fully ambulate. (S1) claimed she made the decision not to accept (C1) back at this facility due to the severity of deteriorating health conditions. (S1-S2) claimed that based on not being able to ambulate and non-complainant with medical medications, and refusing to seek medical attention for a physical and mental condition, the administrators ultimately decided that (C1) require a higher level of care without a written hospital discharge medical assessment. The Department obtained a copy of (C1)’s medical discharge assessment and it stated, “Patient has been calmer for the past couple of days, following commands, more compliant with medications, behaving well.” “Patient is medically stable and cleared for discharge.” There was no indication that (C1) required a higher level of care and must be transferred to a skilled nursing facility.

Based on interviews, observations, and supporting documentation, the facility failed to adhere to Title 22 Regulations Section 80068.5 Eviction Procedures and failed to perform a Needs Services Plan which the client's needs cannot be met by the facility and the client has been allowed to relocate. The preponderance of evidence standard has been met; therefore, the allegation of: "Staff abandoned client at hospital" is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20230324120831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HERITAGE BOARD & CARE #1
FACILITY NUMBER: 198600459
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2023
Section Cited
CCR
80072(2)
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80072 Personal Rights (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement was not met as evidence by:
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The licensee/administrator will review Title 22 Sec 80072. A written statement that Section 80072 will adhere to applicable laws, rules, and regulations. Proof of correction is sent by fax 323-981.1781 to the El Segundo Regional office by 04/04/23.
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Based on interview and record reviews the administrator failed to accord (C1) a safe, healthful and comfortable accomodations. This violation poses a potential health and safety to residents in care.
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Type B
04/04/2023
Section Cited
CCR
80068.5(a)(4)(A)
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80068.5 Eviction Procedures (a) The licensee may, upon 30 days written notice to the client, evict the client ... (4) Inability to meet the client's needs. (A) A Needs and Services Plan modification must have been performed,

This requirement was not met as evidence by.
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The licensee/administrator will review Title 22 Sec 80068.5. A written statement that Section 80068.5 will adhere to applicable laws, rules, and regulations. A will resinstated board & care accomodations for (C1). Proof of correction is sent by fax 323-981.1781 to the El Segundo Regional office by 04/04/23.
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Based on interview and record reviews the administrator failed to provide (R1) a written with an EvictionNotice and failed to perform a Needs and Service Plan. This violation poses a potential health and safety 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: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20230324120831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HERITAGE BOARD & CARE #1
FACILITY NUMBER: 198600459
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2023
Section Cited
CCR
80064(a)(2)(3)
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80064 Administrator - Qualifications and Duties (2) Knowledge of the requirements for providing the type of care and supervision needed by clients...(3) Knowledge of and ability to comply with applicable law and regulation.

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The licensee/administrator will create a plan to ensure that the administrator performs knowledge of and complies with applicable laws, rules, and regulations. A written statement that reviewed 80064 proof of correction sent by fax 323-981.1781 to the El Segundo Regional office by 04/04/23.
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This requirement was not met as evidence by: Based on interview and record reviews the administrator failed to adhere to Title 22 regulations, resulting to multiple citations, This violation poses a potential health and safety 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: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4