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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003908
Report Date: 05/31/2024
Date Signed: 05/31/2024 12:36:39 PM

Document Has Been Signed on 05/31/2024 12:36 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:HERITAGE BOARD & CARE #3FACILITY NUMBER:
306003908
ADMINISTRATOR/
DIRECTOR:
WARREN TRINIDADFACILITY TYPE:
735
ADDRESS:2900 E. 7TH STREETTELEPHONE:
(562) 900-6261
CITY:LONG BEACHSTATE: CAZIP CODE:
90804
CAPACITY: 18CENSUS: 13DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:14 AM
MET WITH:Administrator Mary CruzTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 05/31/24, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Mary Cruz as the purpose of the visit was explained. The facility is licensed to serve eighteen (18) mentally disabled adult ages 18-59, current census is 13. Annual fees are current, surety bond active (6/3/28), Administrator ARF certificate active (10/9/25).

The facility is a single-story structure located in a residential neighborhood and consists of the following: (9) resident bedrooms, (3) client bathrooms, living room, dining room, family room, kitchen, office area, washer and dryer/ storage area, backyard with table and chairs. Kitchen was inspected and observed to be clean and operational. No weapons are stored in the premises, no bodies of water. bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients.

LPA conducted a records review of (3) staff records, (3) client records, and (3) medication administration records, and 2 P&I, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 03/15/24, (3) fire extinguisher fully charged, carbon monoxide and smoke detectors are operational.

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

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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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