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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426762
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:55:02 PM

Substantiated


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
09/12/2024 and conducted by Evaluator Renese Howell-Small
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240912153022
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:
12/17/2024
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Francisco GramonteTIME COMPLETED:
03:54 PM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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On 12/17/2024 at 2:25PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility to deliver findings for the above allegation. LPA explained the purpose of the visit to staff, staff notified the Administrator.

First allegation: Illegal eviction

Regarding the first allegation, Illegal eviction. Based on phone interviews and record review, including emails between the Administrator and the Public Guardian, LPA Small was made aware that Resident #1 (R1) was sent to the hospital on 08/28/2024 and the facility refused to accept R1 back into care because R1 was in need of a higher level of care. Although LPA was provided a copy of the 30-Day Eviction letter, LPA could not confirm that the letter was given to R1 or the Public Guardian. The facility was not allowed to refuse the resident based on title 22 regulation 87224 (a) (2). Based on the evidence gathered during the investigation, the above allegation is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
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 3
Control Number 56-AS-20240912153022
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2024
Section Cited
CCR
87224(a)(2)
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Eviction Procedures A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility or to an independent living arrangement as a result of forfeiture of a license...(2) Provide each resident or the
This standard was not met as evidenced by:
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Administrator will read over regulation and provide a same day written statement indicating the acknowledgement and review of the regulation. Administrator will send a copy of this signed statement to LPA by Plan of Correction due date.
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Based on interviews, observation and record review, the licensee did not ensure that the licensee followed eviction procedures which poses an immediate Health, Safety or Personal Rights risk to persons 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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240912153022
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: 12/17/2024
NARRATIVE
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SUBSTANTIATED is defined as The “preponderance of the evidence” standard has been met.

A deficiency will be cited. On 12/17/2024 at 3:35PM LPA Small spoke with Amparo Liwanag on the phone during the visit and informed her of the findings.

An exit interview was conducted and a copy of this report, LIC9099, LIC9099C, LIC9099D and Appeal Rights was left with staff.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3