<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006571
Report Date: 10/25/2024
Date Signed: 10/25/2024 05:36:52 PM

Document Has Been Signed on 10/25/2024 05:36 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HILLS OF HIGHLAND, THEFACILITY NUMBER:
306006571
ADMINISTRATOR/
DIRECTOR:		DUCLAYAN, JUSTINFACILITY TYPE:
740
ADDRESS:11541 HIGHLAND LANETELEPHONE:
(657) 660-5308
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 4DATE:
10/25/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Licensee Maricel Nepomuceno, Administrator Justin DuclayanTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a single story residential home. LPA along with Licensee Maricel Nepomuceno and Administrator Justin Duclayan toured facility at 3:45 PM and observed the following:

Fire clearance approval was received on 09/17/24. Structure: Facility is a one story, 6 bedroom (4 private Residents bedrooms, 1 shared resident bedroom and 1 staff room area) 5 full bathrooms house with detached garage and a beige exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall and operating landline Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors and carbon monoxide detector are centrally wired and were tested operational. Facility has 3 Fire extinguishers which are mounted and charged. Facility has audible alarms on all sliding/exit doors. Appliances: Electric Stove and refrigerator are operational. Toxins: LPA observed toxins secured in laundry storage area. Sharps are secured in drawer. Water Temperature: Tested and recorded between 108.5 to 111.7 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility does exercises, puzzles, bingo and has activity directors. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on both sides of facility as required. LPA observed shaded outdoor seating and golf green area. Backyard has outside covered Jacuzzi that is non operational.

CONTINUED 809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HILLS OF HIGHLAND, THE
FACILITY NUMBER: 306006571
VISIT DATE: 10/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Administrator's Certificate on file for Justin Duclayan observed on wall effective 10/3/2024- 10/2/2026

Component III Orientation was waived during this pre-licensing visit due to licensee presently operating several facilities.

No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure.


An exit interview was conducted with Administrator and a copy of report was left at facility
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2