Facility Evaluation Report

On 06/01/2023 at 10:00 AM an Office Meeting was held by the El Segundo Adult & Senior Care Program. Present during the meeting RO was informed that Warren Trinidad is no longer administrator. Licensee met with Regional Manager Benita Yates, Licensing Program Manager (LPM)/ Eva Alvarez, Licensing Program Analyst (LPA)/Jose Calderon, Licensee /Lilia Baliwag and Administrator/Mary Cruz to discuss the recent incident report submitted to the department on 5/25/2023.

The following items were discussed, and documents requested during this meeting:

· Recent Secretary of State changes for Heritage Board and Care I, II, III and IV

· Licensee will submit updated Application for a Community Care Facility (LIC 200)

· Licensee will submit Administrative Organization form (LIC 309)

· Register of Facility Client, (LIC 9020) for Heritage Board and Care I, II, III, IV

· Required documents for change of Administrator for Heritage Board and Care I, II, III, IV

· Licensee will provide client financial information (i.e., representative payee or private pay)

Licensee will provide the above information no later than 06/05/2023.