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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608268
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:31:01 PM

Document Has Been Signed on 04/13/2022 03:31 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HERITAGE SENIOR HOME CAREFACILITY NUMBER:
197608268
ADMINISTRATOR:NINO NAVARROFACILITY TYPE:
740
ADDRESS:820 GLENLEA STREETTELEPHONE:
(626) 272-1540
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 6CENSUS: 4DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Licensee Nini Navarro and Michelle Navarro AdministratorTIME COMPLETED:
03:38 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez and Bennette Pena conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with Licensee/Administrator Nino Navarro and Administrator Michelle Navarro and explained the purpose of the visit. Facility serves residents 60 and older. Facility is a single story home located in a residential area consisting of 4 private rooms, one shared room and 1 staff room., 3 bathrooms, living room, dining room, backyard patio area with shade, and attached garage. The last fire drill was completed on March 1, 2022. Administrator certificate expires 05/04/22

The following were observed/inspected:
· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· Three (4) resident rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· All client rooms were not equipped with alcohol-based hand sanitizer but available through out the facility
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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Document Has Been Signed on 04/13/2022 03:31 PM - It Cannot Be Edited


Created By: Alberto Lopez On 04/13/2022 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE SENIOR HOME CARE
FACILITY NUMBER: 197608268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs and Administrator observed hot water facet leaking in main bathroom and window pane missing from one kitchen cabinet. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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Administrator will repair hot water facet in main bathroom and repair the window pane in the kitchen cabinet by POC date and send photo and self cerify to LPA by POC date as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HERITAGE SENIOR HOME CARE
FACILITY NUMBER: 197608268
VISIT DATE: 04/13/2022
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Water temperture was within range of 105-120 degrees F and
Deficiencies cited. (see 809 for details)
Exit interview was conducted with Administrator Nino Navarro and Co Administrator Michelle Navarro. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC809 (FAS) - (06/04)
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