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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600459
Report Date: 12/11/2023
Date Signed: 12/28/2023 03:15:03 PM

Document Has Been Signed on 12/28/2023 03:15 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 ASC, 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) 900-5577
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY: 42CENSUS: 20DATE:
12/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Marilee Cruz - AdministratorTIME COMPLETED:
04:00 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 12/11/2023 at around 8:50 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator Marilee Cruz. LPA explained the purpose of the visit and was accompanied by Administrator inside and outside the facility during this inspection.

This facility is licensed to serve 42 ambulatory mentally ill adults ages 18 – 59 years.
The facility has an approved waiver for incidental medical services provided for clients who have insulin dependent diabetes.

A total of 22 ambulatory clients are currently residing in this facility.

The Annual Licensing Fees are current.

The facility is composed of two buildings in a residential street.
Building 1 is a two-story building that consist of 19 client bedrooms, 6 bathrooms, 1 laundry room, 1 kitchen, 1 staff room, 1 kitchen storage, and 1 file room.
Building 2 is a one-story building that consist of 6 client bedrooms, 2 client toilets, 2 client showers, 1 staff bathroom, 2 offices, 2 storage rooms, 1 tv room, 1 conference room, and 1 dinning room.
There is a backyard patio area with shaded seating.

Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #1
FACILITY NUMBER: 198600459
VISIT DATE: 12/11/2023
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
LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 11/03/2023. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There are around 12 fire extinguisher around the facility and they were last serviced on 03/09/2023. There are two videoconferencing devices (smart phones) dedicated for client use in the office managers office.

5 out of 5 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA tested hot water temperature and it measured between 93 degrees Fahrenheit. This facility provides clients with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. LPA observed damaged walls in one bedroom and in one bathroom.

5 staff records were reviewed, 5 out of 5 staff records had current First Aid Certificates, Criminal Record Clearances, Job Applications, Tuberculosis Test, Facility Trainings/Drills, and signed Employee Rights.

5 client records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Admission Agreements, Medical Assessments, Consent Forms, Weight Record, Emergency Information, Appraisal & Needs Service Plan, Tuberculosis Test, Centrally Stored Medication Destruction Record, Safeguards for Cash Resources, Personal Rights, and Cash Resource Information.

Facility was approved for a grant by the State of California and with that grant the facility will be updating the building.
No deficiencies are being cited based on LPA observations in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, Plans of Corrections were reviewed and developed.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2