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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426762
Report Date: 09/16/2024
Date Signed: 09/16/2024 02:41:09 PM

Document Has Been Signed on 09/16/2024 02:41 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HIGHLAND SENIOR HOME CARE LLCFACILITY NUMBER:
366426762
ADMINISTRATOR/
DIRECTOR:		LIWANAG, AMPAROFACILITY TYPE:
740
ADDRESS:7513 SWEETMEADOW COURTTELEPHONE:
(909) 714-0225
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 6CENSUS: 6DATE:
09/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Francisco Gramonte, StaffTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 09/16/2024 at 12:45 PM, Licensing Program Analysts (LPAs) Renese Howell-Small and Melody Brown met with a staff Francisco Gramonte to initiate a Case Management visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the facility visit today, 09/16/2024, Licensing Program Analysts (LPAs) Howell-Small and Brown observed Staff #3 (S3) working at the facility. S3 reported to LPAs Howell-Small and Brown that S3 started working at the facility the first week of August 2024. LPAs Howell-Small and Brown cross referenced the Guardian database and observed that Staff #3 (S3) has a criminal background clearance, but S3 was not associated to the facility as S3 criminal background clearance was not transferred to the facility prior to employment on 08/2024. Moreover, during the facility visit today, 09/16/2024, Staff #2 (S2) reported to LPA's Small and Brown that S3 started working at the facility on 08/2024. LPA's Howell-Small and Brown informed staff, Gramonte that a deficiency will be issued, and Civil Penalties were assessed with the amount of $500.00 for S3 working at the facility without criminal background clearance transfer prior to employment and will continue to be assessed of $100.00 per day per citation until corrected.

In addition, during the tour of the facility, LPAs Howell-Small and Brown observed one (1) gallon of bleach in the laundry room, and two (2) spray bottles of cleaning solution in the residents’ bathroom and are not locked and are accessible to residents in care. Deficiency will be issued. Moreover LPA's Small and Brown observed that the facility has a non-operable carbon monoxide alarm. A deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to staff Francisco Gramonte.


SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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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Document Has Been Signed on 09/16/2024 02:41 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 09/16/2024 at 01:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HIGHLAND SENIOR HOME CARE LLC
FACILITY NUMBER: 366426762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2024
Section Cited
CCR
87705(f)(2)

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87705(f)(2) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medicatioh, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
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Licensee immediately lock the one (1) gallon of bleach and two (2) spray bottles of cleaning solution during the visit.
Licensee stated to train all staff on CCR 87705(f)(2) and submit proof of staff training log to LPA Small on Plan of Correction (POC) due date.
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based on observation, interview and records review, the Licensee did not comply with the section cited above by not ensuring the one (1) gallon of bleach and two (2) spray bottles of cleaning solution were locked and inaccessible to residents, which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
09/27/2024
Section Cited
CCR87355(e)(2)

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87355(e)(2) Criminial Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569. 17(b) shall prior to working...(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:
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Licensee stated to transfer S3's criminal record cllearance to the facility and submit proof to LPA Small on POC due date.

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based on observation, interview and record review, the Licensee did not comply with the section cited above by not transferring S3's criminal records background clearance to the facilty prior to employment on 08/2024 which poses a potential health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 09/16/2024 02:41 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 09/16/2024 at 02:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HIGHLAND SENIOR HOME CARE LLC
FACILITY NUMBER: 366426762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2024
Section Cited
HSC
1569.311

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Health and Safety Code 1569.311 Carbon monoxide detectors required, inspection. Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards...This requirement is not met as evidenced by:
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Licensee stated to obtain/purchase an operable carbon monoxide detector and submit proof to LPA Small on Plan of Correction (POC) due date.
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Based on observations and interview, the Licnesee did not comply with the section cited above by not ensuring that the carbon monoxide detector at the facility is in good working condition which poses an immedicate health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024


LIC809 (FAS) - (06/04)
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