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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800554
Report Date: 12/23/2021
Date Signed: 12/23/2021 11:44:45 AM

Document Has Been Signed on 12/23/2021 11:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:HIGHLANDS CARE HOME III, THEFACILITY NUMBER:
486800554
ADMINISTRATOR:MARIA M. SALVADORFACILITY TYPE:
740
ADDRESS:349 AUBURN DR.TELEPHONE:
(707) 644-7923
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
12/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Care Giver, Betty TretascoTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at The Highlands Care Home III for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Care Giver, Betty Tretasco and granted access into the facility. Administrator, Lolita Pimentel arrived a 35 minutes later. Second Administrator, Maria M. Salvador arrived 25 minutes later.

LPA toured and inspected the building and grounds, which was found to be unobstructed, clean and in good repair. There were no firearms, weapons, or bodies of water in the home. The amount of fresh and non-perishable foods were within regulation. There is a sufficient amount of hygiene products and linens for residents in care. Toxins and hazardous items are stored in key locked cabinets under the kitchen and bathroom sinks. Water temperature was tested during inspection and found to be appropriate during the inspection. The fire extinguisher was charged and serviced April 2021. There is a total of 5 smoke detectors and 1 carbon monoxide detector, which were all tested during inspection and observed to be operable. Medications were locked and centrally stored. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. First aid kit was appropriate. Facility understands that all beds should be outfitted with mattress pads as per Title 22 Regulations # 87307. LPA also requested the following documents to be sent to the Regional Office, Exception request, LIC 309, LIC 400, LIC 308, LIC 500, updated facility sketch and updated liability insurance.

LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has already been N95 Fit tested. Staff has had training on PPE and PPE is sufficient in the facility.

No deficiencies were cited during today's Required 1- Year inspection. LPA requested Administrator to obtain an Exception for a client in care. Exit interview was conducted and a copy of this report was emailed to the Facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
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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