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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600459
Report Date: 06/01/2023
Date Signed: 06/01/2023 01:19:09 PM

Document Has Been Signed on 06/01/2023 01:19 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 #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: 57DATE:
06/01/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:LICENSEE LILIA BALIWAGTIME COMPLETED:
01:15 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
On 06/01/2023 at 10:00 AM an Office Meeting was held by the El Segundo Adult & Senior Care Program. Present during the meeting RO was informed that Mary Grace Trinidad is no longer administrator. Licensee met with Regional Manager Benita Yates, Licensing Program Manager (LPM)/ Eva Alvarez, Licensing Program Analyst (LPA)/Jose Calderon, Licensee /Lilia Baliwag and Administrator/Mary Cruz to discuss the recent incident report submitted to the department on 5/25/2023.

The following items were discussed, and documents requested during this meeting:
· Recent Secretary of State changes for Heritage Board and Care I, II, III and IV
· Licensee will submit updated Application for a Community Care Facility (LIC 200)
· Licensee will submit Administrative Organization form (LIC 309)
· Register of Facility Client, (LIC 9020) for Heritage Board and Care I, II, III, IV
· Required documents for change of Administrator for Heritage Board and Care I, II, III, IV
· Licensee will provide client financial information (i.e., representative payee or private pay)

Licensee will provide the above information no later than 06/05/2023.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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