306003908-6-2-2023-11-AS-JCAN-CSETUZ-20230602150309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003908
Report Date: 06/02/2023
Date Signed: 06/02/2023 03:03:14 PM

Document Has Been Signed on 06/02/2023 03:03 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 #3		FACILITY NUMBER:	306003908
ADMINISTRATOR:	WARREN TRINIDAD		FACILITY TYPE:	735
ADDRESS:	2900 E. 7TH STREET		TELEPHONE:	(562) 434-1588
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90804
CAPACITY: 18		CENSUS: 11	DATE:	06/02/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	ADMINISTRATOR MARY CRUZ		TIME COMPLETED:	03:30 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 06/02/2023 Licensing Program Analyst (LPA) Jose Calderon initiated an unannounced Case Management visit – Other the above said facility Heritage Board & Care #3. Today’s visit was conducted face to face with administrator Mary Cruz (A1). On 06/02/2023 LPA Calderon tour the facility which consisted of a single-story building to include all common areas which included but were not limited to building entrances, reception areas, office, hallways, restrooms, dining room, kitchen. The LPA Calderon also requested copies of the facility's records which includes but are not limited to S1 employee file and C1 facility file, Incident Reports for C1, fire and police reports. On 06/02/2023 LPA Calderon interviewed Administrator A1 for case management visit. On 06/02/2023 LPA Calderon interviewed S1 for complaint. On 06/02/2023 LPA Calderon interviewed R2-R7 for case management.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE BOARD & CARE #3	FACILITY NUMBER: 306003908
	VISIT DATE: 06/02/2023

NARRATIVE

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A1 relays that all staff are required to call 911 to aid clients if needed. A1 relays that A1 provides first aid training to all staff to include CPR and choking incidents. A1 relays that all staff can decide on their own to give aid or not to provide aid to clients in need. A1 relays that A1 does not think that the procedure to give aid or not is in writing. A1 relays that the fire department stated that C1 passed from a blocked airway and the fire department report would reflect the manor of death. S1 relays that he started dinner at 3:55pm and C1 was the first client in line for dinner. S1 relays that he gave C1 his medication first and then served hamburgers and fries. S1 states that C1 sat down at the dinning room table around 4pm. S1 relays that S1 was serving other client’s food when S1 heard C1 yell out “I’m choking”. S1 relays that C1 walked to the bathroom and fell to the ground, S1 relays that S1 called 911 at 4:03 pm and fire department arrived at 4:15pm. S1 relays that he was given CPR and choking training but did not think he was able to touch the clients. S1 relays that S1 did not give any aid to C1 as S1 did not think S1 had the authorization to give aid. LPA Calderon reviewed S1 first aid training which was done on 02/2023. LPA Calderon reviewed C1 facility file. C1 did not have any prior choking incidents and was able to feed oneself without aid from staff.
LPA Calderon attempted to interview C2-C3 who were witness, but C2-C3 are in day program and were not able to be interviewed.

An exit interview was conducted with administrator Mary Cruz (A1), and a hard copy was provided via email for signature.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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