198600459-8-9-2022-11-AS-PSCT-CH5UVJ-20220809155512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600459
Report Date: 08/09/2022
Date Signed: 08/09/2022 03:55:28 PM

Document Has Been Signed on 08/09/2022 03:55 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	HERITAGE BOARD & CARE #1		FACILITY NUMBER:	198600459
ADMINISTRATOR:	MARY GRACE TRINIDAD		FACILITY TYPE:	735
ADDRESS:	2330 & 2340 EAST 15TH STREET		TELEPHONE:	(562) 433-7314
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90804
CAPACITY: 42		CENSUS: 34	DATE:	08/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Warren Trinidad		TIME COMPLETED:	03:54 PM

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	Licensing Program Analyst (LPA) Perry Scott and LPM Janae Hammond conducted an unannounced annual inspection, with an emphasis on infection control. LPA/LPM was greeted by Warren Trinidad (administrator) and we discussed the purpose of today's visit. This facility is a gated apartment complex with two buildings. Which has a capacity for 42 ambulatory clients and currently has 34 ambulatory clients. This facility is for adults ages 18 through 59. Annual Licensing fees are current. The following was observed/reviewed: Building 2330 consist of a single story. LPA/LPM observed 7 client bedrooms and one bathroom which contains 2 shower stalls and 2 stalls for toilets. LPA/LPM also observed the dining area, administration office, and an office for visitors. Building 2340 consists of 2 stories. Each section has a restroom. There's a kitchen, laundry room, staff break room and cleaning supplies room in this building. LPA observed that in bedroom #1 that the temperature was over 85 degrees. Administrator stated that the client is using a fan and a heater. LPA noted that resident is in a shared unit. Also, the sink was clogged. Administrator noted that it is going to be repaired. There is sufficient closet & drawer space in the client bedrooms. Beds have required linen. · Smoke detectors were tested and operable. The fire extinguishers were last serviced on 03/10/22. Both the smoke detectors and fire extinguishers are located throughout both buildings and in the kitchen. The last fire drill was conducted on 05/17/22. · Carbon monoxide detectors were tested and operable. They are located throughout both buildings. Cleaning solutions, disinfectants are locked in the cleaning supplies room which are inaccessible to clients. These items are stored and locked in a room near the kitchen and in the laundry room.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

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 3

Document Has Been Signed on 08/09/2022 03:55 PM - It Cannot Be Edited

Created By: Perry Scott On 08/09/2022 at 02:20 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE BOARD & CARE #1	FACILITY NUMBER: 198600459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in that the sink was clogged in bathroom # 1. And there are beds and shopping carts on the outside of the property that need to be moved. These items poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2022
	Plan of Correction
1 2 3 4	Administrator stated he will have someone come out and repair the sink by POC due date.

Type B

Section Cited

CCR

80088(a)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the temperature exceeded 85 degrees.This poses a potential health and safety risk to persons in care.
	POC Due Date: 08/12/2022
	Plan of Correction
1 2 3 4	Administrator shall insure that residents rooms are at a comfortable temperature by POC due date. The administrator shall self certify to LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Janae Hammond

LICENSING EVALUATOR NAME:

Perry Scott

LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/09/2022

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
26
27
28
29
30
31
32

Toilets, hand washing and bathing facilities were inspected.
· Hot water temperature was recorded to be between 105* to 109.4*.
· Sufficient supply of extra linen are stored in the laundry room and storage room (located near the kitchen).
· Personal hygiene items such as soap, toilet paper, toothbrush, toothpaste, combs, and feminine napkins are available. These items are stored in a storage room near the kitchen.
· Freezers and refrigerators are clean. Two (2) day supply of perishable and 7day supply of nonperishables are available.
· Sharp knives are locked in the kitchen and they are inaccessible to clients.
· LPA observed enough staff working and providing care & supervision during today's visit.
· First Aid kit was inspected.

During the visit, LPA/LPM observed the following to be in compliance: the facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; every staff was wearing a face covering; the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has a Mitigation Plan Report approved by CCLD.

Deficiencies observed and cited per California Code of Regulations, Title 22, Division 6, Chapter 1 & 6. Refer to LIC 809D.

Exit interview conducted, appeal rights explained, and copy of the report was provided to administrator Warren Trinidad.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3