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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800554
Report Date: 02/03/2023
Date Signed: 02/03/2023 11:00:43 AM

Document Has Been Signed on 02/03/2023 11:00 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Maria M. Salvador, LicenseeTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by lead staff, Clarita Ganotisi; Licensee, Maria M. Salvador was contacted and arrived later in the visit. The facility currently provides care for 6 residents 1 of which was admitted in the hospital at the time of visit. No residents are receiving hospice services and some of which with a of diagnosis of dementia.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with lead staff. Facility was at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 3/31/2022 at the time of the visit. Smoke and carbon monoxide detectors were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food stored properly. Residents are provided various alternative food options per meal with the facility ensuring well balanced and nutritious foods. Residents were observed to be resting after lunch in their respective bedrooms. All resident bedrooms have appropriate lighting and furniture with a supply of extra blankets and linens.

There was a supply of hygiene products and paper products available for resident use. LPA conducted a sample review of staff training and found that all staff have current CPR and 1st Aid training on file. Toxins are stored in a locked cabinet in the facility garage and under bathroom sinks. Lock in resident bathroom is in need of replacing due to difficulties locking however no toxins observed. LPA also observed 1 window screen located in resident bathroom in need of repair. Technical Violation issued. Licensee to submit photo corrections to CCLD.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HIGHLANDS CARE HOME III, THE
FACILITY NUMBER: 486800554
VISIT DATE: 02/03/2023
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Infection Control:
Facility has submitted an infection control plan for review. Posters have been placed at the front door, and facility has a station near facility entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. All staff and visitors were observed to have appropriate face coverings and following facility COVID protocols.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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