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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600459
Report Date: 04/05/2024
Date Signed: 04/05/2024 02:29:55 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2023 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20231130104821
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: 27DATE:
04/05/2024
UNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Administrator Mary CruzTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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9
Staff member physically abused residents
INVESTIGATION FINDINGS:
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On 04/05/24 at 00:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Administrator Mary Cruz as the purpose of today’s visit was explained.

The investigation consisted of the following: On 12/01/23 LPA requested copies of the following documents: current staff and resident rosters, facesheets, emergency I.D. forms, needs and service plans, preplacement appraisals, med list, physician’s reports, and admission agreement for residents #1-5 (R1-R5) and copies of complete employee file for staff #1-14 (S1-S14). On 01/05/24 LPA interviewed Manager (M1), Staff #2-4 (S2-S4), Residents # 1-10 (R1-R10), obtained copies of a staff and resident roster, conducted review of medication administration records, toured the facility as a health and safety check, and requested copies of medication training. On 12/01/24, the investigation was referred to the Community Care Licensing Division Investigations Branch and assigned to investigator Dennis Douglas. On 12/04/23 IB investigator Dennis Douglas interviewed Staff #1 (S1), (M1), (A1), (W1), (W2), and interviewed residents #11-13 (R11-R13).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
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 6
Control Number 11-AS-20231130104821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HERITAGE BOARD & CARE #1
FACILITY NUMBER: 198600459
VISIT DATE: 04/05/2024
NARRATIVE
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The investigation revealed the following:

Allegation- Staff member physically abused residents

It is being alleged facility staff physically assaulted resident with a metal pipe which resulted in a laceration. On 12/04/23 IB investigator interviewed A1 regarding the allegation above, A1 denied the allegation above. Per A1 there was surveillance footage, however footage surveillance system only allows footage to be reviewed for 7 days. On 12/04/23 IB investigator interviewed M1 regarding the allegation above, M1 acknowledged there was an incident outside the facility but reports not being a witness. On 12/04/23 IB investigator interviewed S1 regarding the allegation above, S1 acknowledged that an encounter indeed took place and confirmed picking up a metal pipe and using it to keep R1 from walking towards him however, S1 denies ever striking resident with metal bar. On 12/04/23 IB investigator interviewed R1, R11, R12, and R13 regarding the allegation above, 4 of 4 residents interviewed reported being assaulted by staff while in care.

Based on observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 & 6 are being cited on the attached LIC 9099D. An Immediate civil penalty is assessed in the amount of $500.

Exit interview conducted, appeal rights explained and a copy of this report and appeal rights was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20231130104821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HERITAGE BOARD & CARE #1
FACILITY NUMBER: 198600459
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2024
Section Cited
CCR
80027(a)(3)
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To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating…. This requirement is not met as evidence by:
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Licensee shall schedule a training for all staff including the Administrator by a vendor/trainer to provide training in Personal Rights of Clients. Licensee to submit the sign-in sheets/ certificates, training materials and trainer information to the department to correct the Plan of Corrections.
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Based on interviews conducted, records reviewed the Licensee failed to ensure C1 Personal Rights were not violated. Based on the investigation it revealed that S1 physically assaulted C1. This poses an immediate health & safety risk to clients in care.
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Type B
04/12/2024
Section Cited
CCR
80061(b)(1)(B)
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Reporting Requirements -Upon the occurrence, during the operation of the facility, of any of the events …a report shall be made to the licensing agency within the agency's next working day …In a residential facility…abuse… This requirement is not me as evidence by:
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Licensee shall ensure that all staff including the Administrator receive training on mandated reporting/ reporting requirements and submit proof to the department by POC due date.
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Based on records reviewed the Administrator failed to report the incident of S1 physically abusing C1 once it was the Administrator became aware of the incident. This poses a health & safety risk to clients 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: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2023 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20231130104821

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: 27DATE:
04/05/2024
UNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Administrator Mary CruzTIME COMPLETED:
01:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff member sexually abused residents
Illegal drug activities on the premises
Staff member withholds residents’ medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
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On 04/05/24 at 00:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Administrator Mary Cruz as the purpose of today’s visit was explained.
The investigation consisted of the following: On 12/01/23 LPA requested copies of the following documents: current staff and resident rosters, facesheets, emergency I.D. forms, needs and service plans, preplacement appraisals, med list, physician’s reports, and admission agreement for residents #1-5 (R1-R5) and copies of complete employee file for staff #1-14 (S1-S14). On 01/05/24 LPA interviewed Manager (M1), Staff #2-4 (S2-S4), Residents # 1-10 (R1-R10), obtained copies of a staff and resident roster, conducted review of medication administration records, toured the facility as a health and safety check, and requested copies of medication training. On 12/01/24, the investigation was referred to the Community Care Licensing Division Investigations Branch and assigned to investigator Dennis Douglas. On 12/04/23 IB investigator Dennis Douglas interviewed Staff #1 (S1), (M1), (A1), (W1), (W2), and interviewed residents #11-13 (R11-R13). Allegation- Staff member sexually abused residents
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20231130104821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HERITAGE BOARD & CARE #1
FACILITY NUMBER: 198600459
VISIT DATE: 04/05/2024
NARRATIVE
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It is being alleged that facility staff inappropriately touched the resident while in care. On 12/04/23 IB investigator interviewed A1 regarding the allegation above, A1 denied the allegation above. Per A1, A1 never observed any inappropriate interaction between staff and residents. On 12/04/23 IB investigator interviewed S1 regarding the above allegation, S1 denied the allegation above. On 12/04/23 IB investigator interviewed M1 regarding the allegation above, M1 denied the allegation above and reported being unaware of any romantic relationship between staff and resident. On 12/04/23 IB investigator interviewed R1, R2, R3, R4, R6, R11, R12, and R13 regarding the allegation above, 4 of 8 residents interviewed reported not having any knowledge of the allegation above, 4 of 8 residents interviewed reported observing resident going in and out of staff bedroom but reported not having any knowledge of what takes place in the staffs bedroom.

Allegation- Illegal drug activities on the premises

It is being alleged that facility staff are using illegal drugs on the premises. On 12/04/23 IB investigator interviewed A1 regarding the allegation above, A1 denied the allegation above. Per A1, A1 has not observed staff using illegal drugs on the premises even though being informed of the allegation by an outside agency in 10/2023. 12/04/23 IB investigator interviewed S1 regarding the above allegation, S1 denied the allegation above. IB investigator conducted inspection of S1’s bedroom and did not find ant signs of illegal drugs. On 12/04/23 IB investigator interviewed R1, R2, R3, R4, R6, R11, R12, and R13 regarding the allegation above, 5 of 8 residents interviewed reported not having any knowledge of the allegation above, 3 of 8 residents interviewed reported observing staff under the influence while on facility premises.

Allegation- Staff member withholds residents’ medication.

It is being alleged that when upset facility staff are withholding residents’ medications. On 01/05/24 LPA interviewed Manager (M1) regarding the allegation above, M1 denied the allegation above. Per M1, medications are being administered as prescribed by physician. 01/05/24 LPA interviewed S2-S4 regarding the allegation above, 2 of 3 staff reported they do not administer medications and have no knowledge on medications being withheld. 1 of 3 staff interviewed denied the allegation above and reported medications are provided daily and as prescribed by the physician. LPA unable to interview S1 due to S1 not working at the time of visit. On 01/05/24 LPA interviewed R1-R10 regarding the allegation above, 10 of 10 residents denied the allegation above and reported receiving medication daily. On 01/05/24, LPA conducted a review of (10) Residents Medication Administration Records and did not observe any discrepancies.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20231130104821
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HERITAGE BOARD & CARE #1
FACILITY NUMBER: 198600459
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2024
Section Cited
CCR
80064(a)(2-3)
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Administrate Qualifications & Duties-The administrator shall have the following qualifications: Knowledge of the requirements for providing the type of care and supervision needed…Knowledge of and ability to comply with applicable law and regulations…. This requirement was not met as evidence by:
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Administrator shall review Title 22 Regulations, Mandated reporting and the facility plan of operation . Administrator shall self certify the review and acknowledge understanding to the department by POC due date.
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Based on interviews conducted and records review the Administrator failed to ensure proper procedures and regulations were followed following an incident of alleged physical abuse of C1. This poses a health & safety risk to clients 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: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6