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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426762
Report Date: 03/10/2025
Date Signed: 03/10/2025 03:52:51 PM

Document Has Been Signed on 03/10/2025 03:52 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: 5DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:39 PM
MET WITH:Staff, Pat SalinasTIME VISIT/
INSPECTION COMPLETED:
03:52 PM
NARRATIVE
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On 03/10/2025 at 12:39PM , Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to conduct the required annual visit to the facility. LPA met with staff Pat Salinas and Administrator Amparo Liwanag was contacted via telephoned and informed of the purpose of the visit. LPA greeted staff and was granted entrance into the facility. Administrator Amparo Liwanag arrived to the facility at 2:00PM and gave permission for staff to sign for completed inspection report at the conclusion of the visit. LPA informed Administrator of deficiencies. LPA was informed that there are currently five (5) residents in care.

The facility has three (3) bedrooms, two (2) bathrooms, kitchen, dining area, living room, office, laundry, attached garage and backyard with 2 sheds. LPA completed a walk through of facility with Staff, Pat Salinas, reviewed records and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 120 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarm, charged fire extinguishers and first aid kit.

Posters such as; the personal rights, emergency disaster plan, CCLD complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed to be locked and inaccessible to residents. There is no swimming pool, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 03/10/2025 03:52 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 03/10/2025 at 03:10 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: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview , the licensee did not comply with the section cited above by not ensuring cleaning solutions such as bleach and Ajax were kept locked and inacceisble, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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Staff removed cleaning solutions and placed them in a lock cabinet during the visit. Administrator will train staff on hazardous or dangerous materials and provide LPA a copy of this training by the Plan of Correction due date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, iinterview and record review, the licensee did not comply with the section cited above by not ensuring that once medication is administered, staff must initial each day and time that the medication is given into the MAR, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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Administrator will provide medications training for staff an provide LPA with a record of this training by the Plan of Correction due date and provide a copy of the MAR for the month of March.
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: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/10/2025 03:52 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 03/10/2025 at 03:10 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: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and rrecord review, the licensee did not comply with the section cited above by not ensuring that when fire/earthquake drills are conducted, a log is kept of the day, time and participants, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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Administrator will conduct a Fire/Earthquake drill and submit proof to LPA by the Plan of Correction due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/10/2025
NARRATIVE
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Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly.

Yards/Outside: One shaded patio, one (1) side gates with self-latching handle on the side of the house that leads into the backyard.



Record Review: LPA reviewed three (3) staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans.

Two deficiencies, a Technical Violation and a Technical Assistance were given during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Staff, Pat Salinas.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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