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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426762
Report Date: 11/18/2024
Date Signed: 11/18/2024 03:00:43 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
07/24/2024 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240724160526
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: 6DATE:
11/18/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:staff Elfrida SiagianTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Staff did not accord resident with comfortable accomodations.
Staff did not provide assistance in meeting necessary medical needs for resident.
Staff did not provide resident a copy of the admission agreement.
Unlawful Eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegations listed above. LPA met with staff Elfrida Siagian and explained the purpose of the visit. The Administrator Amparo Liwanag was contact and inform regarding today’s visit. The investigation consisted of staff interviews, resident interviews and record review.

For the allegation, Staff did not accord resident with comfortable accommodations.

During resident interviews 4 out of the 6 residents stated they feel comfortable at the facility. In addition, 4 out of the 6 residents also stated the facility is kept at a comfortable temperature and the AC has not been broken. 2 out of the 6 residents were unable to collaborate on the allegation. In addition, during staff interviews 3 out of the 3 staff stated they ensure residents feel comfortable will accommodate their needs.During facility tour, LPA observed the facility AC unit to be working throughout the hallways, common areas and resident bedrooms.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
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 2
Control Number 56-AS-20240724160526
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HIGHLAND SENIOR HOME CARE LLC
FACILITY NUMBER: 366426762
VISIT DATE: 11/18/2024
NARRATIVE
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For the allegation, Staff did not provide assistance in meeting necessary medical needs for resident.

During resident interviews, 4 out of the 6 residents stated they receive medical assistance by the staff. 2 out of the 6 residents were unable to collaborate on the allegation. In addition, during staff interviews 3 out of the 3 staff informed LPA they meet residents medical needs and will assist with their doctor appointments.

For the allegation, Staff did not provide resident a copy of the admission agreement.

During resident interviews, R1 admitted to LPA the facility did provide an admission agreement copy. During record review, LPA Rico verify R1 had an admission agreement. During staff interviews, 1 out of the 3 staff stated that R1 was provided with a copy of their admission agreement.

For the allegation, Unlawful Eviction.

During staff interviews, S1 stated that R1 did not pay their room and board for the month June 2024. S1 stated they provided the eviction notice to R1 and submitted to the proper documents to Community Care Licensing. S1 also stated the facility is no longer continuing with the process of eviction because R1 has now made their payments. During resident interviews, R1 admitted to not paying their room and board, and also stated they are no longer being evicted. During facility tour, LPA observed R1 is still a resident at the facility and their personal belongs are still located in their bedroom.

During record, LPA verify eviction notice was provided to Community Care Licensing.

Based on the evidence found during the investigation, the four (4) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.



An exit interview was conducted, and this report (LIC9099) was discussed and provided to staff Elfrida Siagian.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2