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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003908
Report Date: 11/01/2021
Date Signed: 11/01/2021 03:37:48 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2021 and conducted by Evaluator Jade Jordan
COMPLAINT CONTROL NUMBER: 11-AS-20211027113827
FACILITY NAME:HERITAGE BOARD & CARE #3FACILITY NUMBER:
306003908
ADMINISTRATOR:WARREN TRINIDADFACILITY TYPE:
735
ADDRESS:2900 E. 7TH STREETTELEPHONE:
(562) 434-1588
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY:18CENSUS: 15DATE:
11/01/2021
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Grace TrinidadTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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9
Client requires a higher level of care than facility is providing.
INVESTIGATION FINDINGS:
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On 11/01/21 Licensing Program Analyst (LPAs) Jade Jordan And Ngozi Nwakoro conducted an
Unannounced visit regarding the allegation above. LPA’s were met by Facility Administrator Mary Grace Trinidad, and the purpose of the visit was explained.

The investigation Consisted of: Physical Plant tour, Staff/Resident Interviews, Pertinent documents
Requested: Admissions agreement, staff roster, client rosters, warnings, Physicians Report, appraisal needs and services, functional capability assessment.

***Continued on 9099C****
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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 2
Control Number 11-AS-20211027113827
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HERITAGE BOARD & CARE #3
FACILITY NUMBER: 306003908
VISIT DATE: 11/01/2021
NARRATIVE
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Regarding Allegation: Client requires a higher level of care than facility is providing.

Interviews with staff revealed that Client 1 (c1) needs prompting to shower, take medications, change clothing, wash hands, and change mask. C1 sometimes refuses to do so. Staff stated that c1 will sometimes defecate in pants, due to not wanting to wear prescribed diapers, stated to staff “they are itchy” Staff stated C1is not always compliant right away, with areas listed c1 needs help in. Staff indicated, eventually c1 will listen to staff, may take a couple times to be prompted. Although prompting and reminders are given. C1 will allow staff to physically assist with bathing twice a week. Record review revealed Physicians Report dated 01/06/21 indicates C1 can toilet without, assistance, and Needs prompting for personal care, and hygiene. LPAs physically observed C1 in bed. C1 had a clean white t-shirt, clean pajama bottoms, a clean mask, and no visible stains were seen on hands, clothing

or any other part of C1’s body. C1 stated that they are compliant, and take showers on a regular basis, and does not need assistance with toileting. Based on LPA interviews, Record Review, and observation Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

A copy of this report was provided, Exit interview conducted. No citations issued during

this visit.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2