Community Care Licensing

Document Has Been Signed on 01/14/2024 12:16 PM - It Cannot Be Edited

FACILITY NAME:	HIGHLANDS CARE HOME III, THE		FACILITY NUMBER:	486800554
ADMINISTRATOR:	MARIA M. SALVADOR		FACILITY TYPE:	740
ADDRESS:	349 AUBURN DR.		TELEPHONE:	(707) 644-7923
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY: 6		CENSUS: 5	DATE:	01/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Marilyn Carlos		TIME COMPLETED:	12:25 PM

SUPERVISORS NAME: Troy Ordonez LICENSING EVALUATOR NAME: Kerry Hiratsuka LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2024

Link to Parent Document Below:

FACILITY NAME: HIGHLANDS CARE HOME III, THE	FACILITY NUMBER: 486800554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2024

Type A

Section Cited

CCR

87555(b)(26)

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because LPA observed a near empty refridgerator and freezer, and the nonperishable food supply will not sustain three meals a day for seven days, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2024
	Plan of Correction
1 2 3 4	By 01/15/2024, Licensee shall submit a written plan of correction how they shall ensure the perishable and nonperishable food supply shall be maintained per the regulations.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Kerry Hiratsuka LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2024

Link to Parent Document Below:

FACILITY NAME: HIGHLANDS CARE HOME III, THE	FACILITY NUMBER: 486800554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2024

Type A

Section Cited

CCR

87458(c)

Medical Assessment The licensee shall obtain an updated medical assessment when required by the department This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and record review, the licensee did not comply with the section cited above because LPA observed one resident (R1) leave the facility and when LPA reviewed the physician's report the physician's report stated the resident may not leave unassisted, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2024
	Plan of Correction
1 2 3 4	By 01/15/2024, Licensess shall at minimum schedule a medical appointment for R1 to have another medical assessment done to determine if R1 is able to the leave the facility by themselves. The medical appointment shall be scheduled as soon as possible. If the doctor determines R1 is not able to leave the facility unassisted then the licensee shall come up with a written plan of care to addres R1 wishing to leave the facility for personal reasons.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Kerry Hiratsuka LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2024

Link to Parent Document Below:

FACILITY NAME: HIGHLANDS CARE HOME III, THE	FACILITY NUMBER: 486800554
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2024

Type B

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accomodations, furnishings, and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above because there are locks on the freezer and refridgerator which LPA was told are locked at night. The locks are not locked during the day, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/26/2024
	Plan of Correction
1 2 3 4	By 01/26/2024, the locks on the freezer and refridgerator shall be removed or if the licensee wishes to continue to use it the licensee shall submit for a waiver.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Kerry Hiratsuka LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2024