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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426762
Report Date: 12/14/2023
Date Signed: 12/14/2023 09:54:37 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2020 and conducted by Evaluator Kathleen Banrasavong
COMPLAINT CONTROL NUMBER: 18-AS-20201008152610
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:
12/14/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Amparo LiwanagTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Facility did not provide coverage by personnel with adequate qualifications in administrator's absence.
Facility did not complete the admission agreement within seven days following admission.
Facility did not provide a copy of the admission agreement to the resident's representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to commence a complaint investigation regarding the allegations listed above. LPA met with Caregiver, Franciso Gramonte and spoke over the phone with Administrator, Amparo Liwanga, and explained the purpose of the visit and the elements of the allegations. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and residents, and record review. LPA Banrasavong was unable to contact additional witness, staff, and Resident in order to obtain additional information. Resident passed away 10/05/2020.

On 10/08/2020, Community Care Licensing received a complaint stating that the facility did not provide coverage by personnel with adequate qualifications in administrator's absence, facility did not complete the admission agreement within seven days following admission, and facility did not provide a copy of the admission agreement to the resident's representative.
(Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20201008152610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HIGHLAND SENIOR HOME CARE LLC
FACILITY NUMBER: 366426762
VISIT DATE: 12/14/2023
NARRATIVE
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(Continuation from 9099)

In regards to the allegation that the facility did not provide coverage by personnel with adequate qualifications in the administrator’s absence. It was reported that Administrator, Amparo Liwanag left unqualified staff in charge at the facility in her absence. The allegation stated that the staff called an additional witness after finding Resident 1 (R1) in need of medical attention. It was reported that the additional witness had to advise the staff to call 911. LPA Banrasavong was unable to obtain additional information and/ or documentation pertaining to the incident.

In regards to the allegation that the facility did not complete the admission agreement within seven days following admission and did not provide a copy, it was alleged that the administrator did not provide the responsible party of R1 with a completed copy of the admission agreement. During the investigation, LPA requested documents pertinent to the investigation; however, Administrator stated that the documents older than 3 years were discarded and she does not have any documents from Resident’s file. Administrator stated she always provided the admission agreement to every resident prior to their residency. Additional information could not be obtained.
(Continued on 9099-C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20201008152610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HIGHLAND SENIOR HOME CARE LLC
FACILITY NUMBER: 366426762
VISIT DATE: 12/14/2023
NARRATIVE
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(Continuation from 9099)

Based on LPA’s observation, interview conducted, and record reviews, the preponderance of evidence shows that the allegations of facility did not provide coverage by personnel with adequate qualifications in administrator's absence, facility did not complete the admission agreement within seven days following admission, and facility did not provide a copy of the admission agreement to the resident's representative, there is not enough evidence to show that the allegations did or did not occur.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation are unsubstantiated.

An exit interview was conducted, a copy of this report, along with the LIC 811, was provided to the Administrator, Amparo Liwanga and signed by the Caregiver, Franciso Gramonte.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3