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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426762
Report Date: 02/24/2022
Date Signed: 02/24/2022 01:26:15 PM

Document Has Been Signed on 02/24/2022 01:26 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HIGHLAND SENIOR HOME CARE LLCFACILITY NUMBER:
366426762
ADMINISTRATOR:LIWANAG, AMPAROFACILITY TYPE:
740
ADDRESS:7513 SWEETMEADOW COURTTELEPHONE:
(909) 714-0225
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Francisco GramonteTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Anna Bueno arrived at the facility to conduct an unannounced annual inspection with an emphasis on infection control. LPA met with staff Patricia Salinas and LPA explained the nature of today's visit. There are currently 5 residents in the facility. Salinas confirmed there are no active and/or suspected COVID-19 cases in the facility. Salinas phoned administrator Amparo Liwanag who informed LPA that they will not be able to visit the facility at this time.

LPA toured the facility with staff Gramonte. LPA observed one point of entry for universal symptoms screening that is initiated for all residents, staff and visitors. Signs have been posted throughout the facility, specifically for proper hand washing, cough/sneeze etiquette, and social distancing practices. Facility has a plan in place to monitor any changes in condition for staff and residents. LPA observed a sufficient supply of hand hygiene, cleaning and disinfecting items. LPA observed an adequate supply of Personal Protective Equipment (PPE) that included masks, face shields, gloves, and gowns. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. The facility has a COVID mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning/sanitizing/disinfecting and monitoring of individuals for COVID-like symptoms.

Per California Code of Regulations, Title 22, Division 6, there are no deficiencies cited during this visit. Technical advisories were issued to switch the garage door keyed knob inside the home to limit garage access by the use of a key and maintain consistent screening policies. An exit interview was conducted where this report was discussed with and a copy was provided to Francis Gramonte.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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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