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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003908
Report Date: 06/05/2023
Date Signed: 06/07/2023 09:34:24 AM

Document Has Been Signed on 06/07/2023 09:34 AM - 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 #3FACILITY NUMBER:
306003908
ADMINISTRATOR:WARREN TRINIDADFACILITY TYPE:
735
ADDRESS:2900 E. 7TH STREETTELEPHONE:
(562) 434-1588
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY: 18CENSUS: 11DATE:
06/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:ADMINISTRATOR MARY CRUZTIME COMPLETED:
03:30 PM
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On 06/05/2023 at 08:40 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Heritage Board & Care #3 Facility. LPA Jose Calderon was allowed entry into the facility by Administrator Lilia P Baliwag. Administrator Lilia P Baliwag was asked questions regarding the full care tools control package (13) sections. Staff took LPA Jose Calderon temperature prior to entrance into the facility. The facility is licensed for eighteen (18) adult clients with developmental disabilities. Currently, there are eleven (11) residents residing in the facility with developmental disabilities.

LPA Jose Calderon explained to Administrator Lilia P Baliwag, the purpose of the one-year (1) Annual Inspection visit, and escorted LPA Jose Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Jose Calderon reviewed: Nine (9) resident service records, nine (9) resident medication records, three (3) staff records. LPA Jose Calderon interviewed five (5) residents and three (3) staff members for visit. LPA Jose Calderon inspected the inside facility and outside grounds to include all common areas. The facilities’ last fire drill was conducted on 03/18/2023. The one-story commercial residential home consists of nine (9) resident bedrooms, three (3) resident bathrooms, living room, dining room, family room, kitchen, office area, washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day (2) supply perishable and seven-day (7) supply of non-perishable foods are present in the facility. Emergency Water seven-day (7) supply is found in the garage.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2023
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: 06/05/2023
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LPA Jose Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has NO central air and heating. LPA Jose Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Jose Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Jose Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 108 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 109 degrees Fahrenheit, bathroom #3 hot water temperature properly measured at 108 degrees Fahrenheit. Kitchen hot water temperature properly measured at 111 degrees Fahrenheit. Facility fifteen (15) carbon Monoxide and fifteen (15) Smoke Detectors are battery supplied and were tested and are working properly. The facility four (4) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet in the kitchen. Facility first aid kit three (3) is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. LPA Jose Calderon reviewed nine (9) resident files and found to be complete. LPA Jose Calderon reviewed nine (9) resident medications and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. LPA Jose Calderon noted the Administrator Lilia P Baliwag Certification # 6010204735 expiration date of 02/14/2024 was valid at time of visit. The facility does handle resident's money/cash resources and Surety bond is needed. RLI Surety #RSB0594592 for $3000.00 expiration date 08/08/2024 was valid at time of inspection. Commercial General Liability Policy #ACP GLO 3029967190 policy period from 11/21/2022 to 11/21/2023 and a Commercial Professional Liability Insurance Policy #ACP GLO 3029967190 policy period from 11/21/2022 to 11/21/2023 underwritten by Nationwide Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Jose Calderon spoke to Administrator Lilia P Baliwag who will email full copy of insurance contact which shows all coverages to LPA Jose Calderon by 06/09/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Jose Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Jose Calderon reviewed the resident roster, LPA Jose Calderon confirmed residents’ interview are on resident roster.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
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: 06/05/2023
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During the visit, LPA Jose Calderon observed the facility infection control practices. LPA Jose Calderon observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA Jose Calderon observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA Jose Calderon observed the facility has a thirty-day (30) supply of Personal Protective Equipment (PPE).

LPA Jose Calderon advised the Administrator Lilia P Baliwag to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Jose Calderon did not observe any deficiencies therefore NO citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Lilia P Baliwag.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC809 (FAS) - (06/04)
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