198600455-6-28-2021-11-AS-MCAA-C74UN5-20210922154322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600455
Report Date: 06/28/2021
Date Signed: 06/28/2021 04:33:39 PM

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
06/15/2021 and conducted by Evaluator Jade Jordan

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210615165054

FACILITY NAME:	HERITAGE BOARD & CARE #4		FACILITY NUMBER:	198600455
ADMINISTRATOR:	WARREN TRINIDAD		FACILITY TYPE:	735
ADDRESS:	1509 EAST 4TH STREET		TELEPHONE:	(562) 437-2070
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	20	CENSUS:	DATE:	06/28/2021
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Mary Grace Trinidad		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Facility staff did not provide appropriate supervision to resident
Resident's responsible person was not notified of incident

INVESTIGATION FINDINGS:

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On 06/28/21 Licensing Program Analysts (LPAS) Jade Jordan, and Jennifer Jones conducted a subsequent visit to deliver findings for the above allegations. LPA's Met with Administrator Mary Grace Trinidad; and the Purpose of the visit was explained.

Regarding Allegation: Facility Staff did not contact responsible party

On 05/08/21 C1 was taken to the hospital by ambulance for a serious self-inflicted injury. The mother of C1 stated that she is the Emergency Contact, although she is not C1’s conservator. During interview, C1’s mother stated that she was not notified by the facility of the incident, but by C1’s Department Of Mental Health (DMH) Caseworker. The caseworker does not work for the facility. Based on LPA Record Reviewed; C1 listed Mother as emergency contact.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

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 4

Control Number 11-AS-20210615165054

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 #4	FACILITY NUMBER: 198600455
	VISIT DATE: 06/28/2021

NARRATIVE

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Based on interviews with administrator it was stated that C1’s emergency contact was called by the facility, but she did not pick up, and they did not leave a message. A secondary phone call was not made to inform Emergency Contact.

Therefore, based on interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) us found to be SUBSTANTIATED. California Code Of Regulations, (Title 22, Division, Chapter #), are being cited on the attached LIC 9099 D.”)

Regarding Allegation: Facility staff did not provide appropriate supervision to resident.

On 05/08/21 C1 was taken to the hospital for a serious self-inflicted injury. According to SIR night staff was in their room and a client had to come get staff to inform of the self-injury that C1 had inflicted upon self. Another resident called 911. The incident was discovered at 3am. Based on LPA interviews, Observation and record review it was determined that staff was not available to assist

Therefore, based on interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) us found to be SUBSTANTIATED. California Code Of Regulations, (Title 22, Division, Chapter #), are being cited on the attached LIC 9099 D.”)

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20210615165054

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 #4	FACILITY NUMBER: 198600455
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/28/2021 Section Cited CCR 85072(2)	1 2 3 4 5 6 7	85072 (2) Personal Rights To have the facility inform his/her relatives and authorized representative, if any, of activities related to his/her care and supervision, including but not limited to notification of any modifications to the needs and services plan.	1 2 3 4 5 6 7	Admin put a plan in place for staff to contact clients Emergency contact/ RP. Send to LPA in writting by 07/09/21
	8 9 10 11 12 13 14	This standard was not met as evidenced by: LPA observed C1's Face Sheet; And C1 listed his mother as emergency contact. C1's DMH caseworker is who notified C1's emergency contact. This poses a potential Personal Rights, health and safety risk to residents in care	8 9 10 11 12 13 14
Type B 06/28/2021 Section Cited CCR 85065.6(b)(d)	1 2 3 4 5 6 7	85065.6 Night Supervision b) Employees providing night supervision from 10:00 p.m. to 7:00 a.m.... shall be available to assist in the care and supervision... and shall have received training in the following (d) In facilities providing care and supervision for 16 to 100... and awake. Another person shall be on call and capable of responding within 30 minutes.	1 2 3 4 5 6 7	Admin will submit a plan ensuring that night staff will be awake during the hours of 10pm-7am. Send to LPA in writting by 07/09/21
	8 9 10 11 12 13 14	This standard was not met as evidence by: Clients in care informed staff of client injury, and clients contacted 911. This poses a potential Personal Rights, health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
06/15/2021 and conducted by Evaluator Jade Jordan

COMPLAINT CONTROL NUMBER: 11-AS-20210615165054

FACILITY NAME:	HERITAGE BOARD & CARE #4		FACILITY NUMBER:	198600455
ADMINISTRATOR:	WARREN TRINIDAD		FACILITY TYPE:	735
ADDRESS:	1509 EAST 4TH STREET		TELEPHONE:	(562) 437-2070
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90802
CAPACITY:	20	CENSUS:	DATE:	06/28/2021
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Mary Grace Trinidad		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Facility staff did not properly assist resident with their medication

INVESTIGATION FINDINGS:

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On 06/28/21 Licensing Program Analyst Jade Jordan, and Jennifer Jones conducted a subsequent visit to deliver findings for the above allegations. LPA's Met with Administrator Mary Grace Trinidad; and the Purpose of the visit was explained.

Regarding allegation: Facility staff did not properly assist resident with their medication.
LPA interviewed 10% of clients in care, all generally stated that they receive their medication from staff, and that they take their medication. LPA Reviewed the MAR” S Record for C1. LPA observed one day recorded, where C1 refused to take medications. All other dates were signed off by staff certifying that C1 was given and had taken medication during prescribed times and dates. Therefore, 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

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade Jordan	TELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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