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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003908
Report Date: 04/17/2024
Date Signed: 04/17/2024 07:36:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/29/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220329131607
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: 13DATE:
04/17/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
03:01 PM
ALLEGATION(S):
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Staff did not communicate with authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced visit to the facility and was greeted by Administrator (A3: Mary Cruz). LPA conducted a risk assessment prior to entering the facility. A1 informed LPA that the facility has no COVID cases nor do the clients or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation.

An initial 10-Day visit was conducted by LPA Lourdes Montoya on 04/06/22 who was met by Administrator (A1: Warren Trinidad). During that visit, LPA Montoya requested and reviewed copies of service records for Clients #1 – #5 and other pertinent documents pertaining to the above-mentioned allegation. Together with Administrator, LPA Montoya toured the facility’s physical plant for the health and safety of clients in care.

(Evalution Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
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 7
Control Number 11-AS-20220329131607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #3
FACILITY NUMBER: 306003908
VISIT DATE: 04/17/2024
NARRATIVE
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Interviews conducted of Staff (S1, S4) on 04/04/24 corroborated that the facility maintains Caregiver Notes (dated 02/20/22 – 02/24/22) regarding clients’ incidents; and they will report it to the House Manager who reports it to the Administrator. Facility staff replied that they did not receive a complaint from Client #1’s Conservator/Responsible Person on or about 02/20/22 – 02/25/22 regarding staff not communicating to Client #1’s authorized representative. Facility staff confirmed that they are aware of being a Mandated Reporter and receive in-service training on an annual basis. Facility staff also confirmed having received Mandated Reporter training upon hire. [A review of facility staff In-Service Training Sign-in Sheet on the topic of Mandated Reporting was dated MM/DD/YY.] Administrator #3 (A3: Mary Cruz) confirmed that the House Managers will report serious incidents if it cannot be handled at the lower level. LPA/RA Ceniceros conducted virtual interviews on 04/04/22 with Clients (C2, C3, C4, C9) who corroborated that they have not had concerns with the facility not reporting an incident that involved them or not communicating an incident to their conservator/responsible person; however, the majority are their own responsible person. [Facility staff In-Service Training Sign-in Sheet on the topic of Reporting Requirements was dated MM/DD/YY, Unusual Incident/Injury Report (dated 02/22/22), staff work schedules & roster (February 2022), clients’ roster (February 2022), and Client #1’s Emergency Identification Information/Face Sheet (dated 01/01/22) were reviewed.

Regarding Allegation #2: this investigation revealed that the facility failed to notify reporting agency (CCLD) and appropriate parties (Conservator/Responsible Person) regarding an incident that occurred on 02/20/22 involving Client #1’s hospitalization - including an update [based on the “Unusual Injury/Incident Report” (dated 02/22/22)] regarding Client #1’s hospitalization status. LPA/RA Ceniceros reviewed the facility’s incident reports and observed that the facility failed to submit a LIC 624 form regarding Client #1’s incident that occurred on 02/20/22 (hospital admittance) and on 02/25/22 (hospital discharge). In addition, facility failed to submit a “Death Report” (dated 02/25/22) to reporting agency (CCLD) and/or document


if notification was made to appropriate parties (Conservator/Responsible Person) regarding Client #1’s passing on 02/25/22.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of PERSONAL RIGHTS: “Staff did not communicate with authorized representative” is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citations issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the Administrator (Mary Cruz).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/29/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220329131607

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: 13DATE:
04/17/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
03:01 PM
ALLEGATION(S):
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Resident(s) under the influence of drugs and alcohol while in care.
Staff did not safeguard the resident’s belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced visit to the facility and was greeted by Administrator (A3: Mary Cruz). LPA conducted a risk assessment prior to entering the facility. A1 informed LPA that the facility has no COVID cases nor do the clients or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation.

An initial 10-Day visit was conducted by LPA Lourdes Montoya on 04/06/22 who was met by Administrator (A1: Warren Trinidad). During that visit, LPA Montoya requested and reviewed copies of service records for Clients #1 – #5 and other pertinent documents pertaining to the above-mentioned allegation. Together with Administrator, LPA Montoya toured the facility’s physical plant for the health and safety of clients in care.

(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20220329131607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #3
FACILITY NUMBER: 306003908
VISIT DATE: 04/17/2024
NARRATIVE
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This complaint investigation was referred to the California Department of Social Services (CDSS) Investigation Bureau (IB) and was assigned to Investigator Dennis Seng which included a review of Client #1’s medical records from Long Beach Memorial Care Hospital (dated 02/20/22 – 02/25/22). There was reported law enforcement contact for the incident on 02/20/22 conducted by Long Beach Police Department; however, a supplemental report was completed on 07/07/22; as there was no record of police report available from Long Beach P.D. at the time. Interviews were conducted of hospital medical staff, law enforcement personnel, witnesses, facility staff, and clients in care. A review of the facility’s records for Client #1: Admission Agreement (dated 02/04/14), House Rules (dated 01/01/18), Physician’s Report (dated 01/18/22), Progress Notes (dated 05/02/18), Updated Appraisal/Needs and Services Plan (dated 04/27/21), Medication Administration Record (MAR February 2022), Caregiver Notes (dated 02/20/22 – 02/24/22), Unusual Incident/Injury Report (dated 02/22/22), facility staff “In-Service Training” records, staff work schedules (February 2022), Staff & Clients’ rosters (February 2022)].

Regarding Allegation #1: this investigation revealed that Client #1 arrived at Long Beach Memorial Care on 02/20/22 at 2:13 p.m. from an overdose of methamphetamines. Medical records (dated 02/20/22 – 02/25/22) documented that Client #1 was found down by facility staff 10 minutes prior to paramedic’s arrival and started CPR. Client #1 regained pulse after 12 minutes. Given full arrest, all labs and imaging were discussed with Client #1 at length and all questions answered. Client #1 understood and agreed with this plan for admission. Client #1 was personally seen and evaluated by an ER physician of Critical Care Medicine who participated in client’s care - approximately 35 minutes. Time included discussion with the client and family as to the diagnosis, potential treatments, and risk/benefits; as well as discussion with admitting/consulting physicians regarding this case. Decision was made by family that Client #1 would not want to pursue long-term life support. Client #1 was ultimately discharged from the hospital w/hospice orders on 02/25/22. Client #1 was eventually removed from life support and passed away on 02/25/22. Client #1’s death was attributed to an overdose of methamphetamines and alcohol use. A review of the Physician’s Report documented that the client “uses street drugs” but there was no direct course of action to address this issue on the client’s Appraisal/Needs and Services Plan. LPA/RA reviewed Client #1’s “Physician’s Report” (dated 01/18/22) under “Capacity for Self-Care” documented that Client #1 “able to leave facility unassisted” and under “House Rules” entitled “No Alcohol and/or Illegal Drugs Policy” was signed by

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20220329131607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #3
FACILITY NUMBER: 306003908
VISIT DATE: 04/17/2024
NARRATIVE
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Client #1 and dated 01/01/18. Based on interviews Client #1 was adequately supervised and facility staff conducted general body checks and room checks (approximately) 3:00 p.m. and at 8:00 p.m. every day – checking for sharp objects, alcohol, and drugs. Client #1 was provided with their prescribed medications as their diagnosis was well managed (minimal agitation/pacing). [A review of Client #1’s medication administration record (February 2022) documented that the client’s prescribed medications were administered by facility staff (via signatures) and there was no documentation of a physician’s order for methamphetamines prescribed to the client.] Facility staff adequately administered Client #1’s medications as the client’s symptoms lessened and displayed mild behavior and was less agitated and stabilized. Facility allowed Client #1 to come and go from the facility. [A review of client’s “Physician’s Report” (dated 01/18/22) under “Capacity for Self-Care” documented that Client #1 was “able to leave facility unassisted”.] Client #1 got the street drugs outside of the facility and when Client #1 returned to the facility, the client walked in front of their room and passed out; and facility staff called 9-1-1 (approximately) 1:30 p.m. (A review of Client #1’s facility records: “House Rules” entitled “No Alcohol and/or Illegal Drugs Policy” was signed by Client #1 and dated 01/01/18.) Although the facility was aware of Client #1’s prior history with street drugs, facility staff were unable to prevent the client from accessing those drugs outside of the facility.

Based on the evidence gathered, interviews conducted, and medical records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: “Resident(s) under the influence of drugs and alcohol while in care” is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed based on virtual interviews conducted of Facility Staff (S1 – S4) corroborated that they have not received complaints from clients or conservator/responsible person/family member that they’ve had their personal property or valuable items missing. Facility staff also confirmed that the facility does not provide scrubs to the clients; as facility staff members are the ones to wear scrubs during their work shift. Facility staff confirmed that they receive in-service training on the topic of client’s personal rights on an annual basis. [Facility staff “In-Service Training” records on the topic of “Client/Resident Personal Rights” and Client #1’s facility records entitled, “Client/Resident Personal Rights” (dated 01/01/22).] LPA/RA Ceniceros interviewed Clients (C2, C3, C4, C9) who corroborated that they have not had to report personal property or valuable items missing nor had they observed other clients wearing scrubs due to missing their clothing. [Facility records entitled, “Client/Resident Personal Property and Valuables” (dated 02/04/14); staff work schedules & roster (February 2022), and clients’ roster (February 2022)] were reviewed.]

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20220329131607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #3
FACILITY NUMBER: 306003908
VISIT DATE: 04/17/2024
NARRATIVE
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Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: “Staff did not safeguard the resident’s belongings” is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to the Administrator (Mary Cruz).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20220329131607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #3
FACILITY NUMBER: 306003908
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2024
Section Cited
CCR
80061(b)
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Reporting Requirements. Upon the occurrence, of specified events, reports shall be made to the licensing agency within the agency's next working day. In
addition, written reports shall be submitted to the licensing agency within seven days following the occurrence of such events. This requirement is not met as evidenced by:
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Licensee/Administrator shall read Title 22, Section "Reporting Requirements" and send a written plan detailing how Licensee/Administrator will ensure that an incident is reported to CCLD, and notification made to client’s Conservator/Responsible Person as required according to the regulations. Administrator must conduct in-service training and provide a copy of the sign-in sheet of all facility staff in attendance. Plan of Correction (POC) is due to the CCLD/El Segundo ASC Regional Office by 04/18/24. Sent POC to elizabeth.ceniceros@dss.ca.gov

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A review of the facility’s incident reports (February 2022) via SharePoint, the facility failed to report to CCLD) or document that notifications were made to Client #1’s Conservator/Responsible Person of an incident that occurred on 02/20/22 involving the client’s hospitalization or an update on
02/22/22 regarding the client’s hospitalization status. This violation is an immediate health or safety to resident's in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7