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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608268
Report Date: 06/02/2023
Date Signed: 07/10/2023 10:24:19 AM

Document Has Been Signed on 07/10/2023 10:24 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
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: 6DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Nino Navarro and Michelle NavarroTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Angelica Rea conducted the unannounced required annual inspection on today's visit. LPA met with Licensee/Administrators, Nino Navarro and Michelle Navarro who assisted with the visit. The 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(s), dining room, backyard patio area with shade, and attached garage. The last fire drill was completed on 3/8/23. Administrator(s) certificate(s) expire on 05/04/24, and 4/10/24, respectively.

The following were observed/inspected:
Four (4) resident rooms, 1 staff room, common areas, bathrooms, and outdoor physical plant was inspected. Three (3) centrally stored client medication records were reviewed. Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. All required postings were observed. PPE supplies were observed. Smoke Detectors and carbon monoxide detectors, tested and operating. Staff and resident files were reviewed during today's visit. Cleaning supplies, and toxins are stored in a locked cabinet in the laundry area. Water was tested in kitchen and 3 bathrooms. Water temperature measured between 112.2 degrees F and 113.4 degrees F in all faucets measured. Designated area for centrally stored medication is located in locked kitchen cabinet. A first-aid kit has been inspected and has the following : thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in locked kitchen cabinet.

There are no deficiencies issued today. The exit interview was held. A copy of this report was given to Michelle Navarro..
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2023
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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