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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602976
Report Date: 10/22/2021
Date Signed: 10/22/2021 02:52:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HERITAGE RESIDENTIAL HOME CAREFACILITY NUMBER:
198602976
ADMINISTRATOR:NAVARRO, NINO SUNGLAOFACILITY TYPE:
740
ADDRESS:2322 SIENA CTTELEPHONE:
(626) 272-1540
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Nino Navarro - AdministratorTIME COMPLETED:
03:05 PM
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Licensing Program Analysts (LPAs) Luis Mora and Tony Vasallo conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPAs met with Administrator Nino Navarro and explained the reason for the visit. The physical plant was toured, resident files and medications records were reviewed, staff files were reviewed and food supply was inspected.
LPAs and Administrator toured the facility which included the following: 5 resident rooms, 3 bathrooms, living room, television room, dining room, kitchen, sitting area, office room, laundry room, attached garage and backyard. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in 2 resident bathrooms and measured between 108F - 111F degrees which is within the required 105F - 120F degrees. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. There is a closet in the hallway with extra clean linen. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and in each resident room. Carbon monoxide detectors were observed in the hallways. Auditory devices were seen on exit doors which are required for dementia residents and were operating a the time of visit. LPAs observed 2 fire extinguishers throughout the facility which were fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Cleaning supplies and toxins are locked and are inaccessible to residents. First Aid kits were inspected and were fully stocked with current manuals. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed. 6 out of 6 resident files and medications records were reviewed. 2 staff files were randomly selected for review. Medications are centrally stored in a locked closet in the living room. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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