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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800554
Report Date: 03/15/2024
Date Signed: 03/18/2024 01:23:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2024 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240215083304
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: 4DATE:
03/15/2024
UNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Francesca Cristobal, care staff and Lolita Pimentel, care staffTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff do not distribute residents' medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced, for the purpose of gathering additional information and delivering findings, regarding the above listed allegation. LPA met with care staff, Francesca Cristobal, reviewed records and made observations. Staff, Lolita Pimentel arrived towards the end of the visit.

It was alleged staff do not distribute residents' medications as prescribed. Investigation revealed, several discrepancies in documentation and dispensing of residents medication. LPA Canela conducted a medication count and it revealed R1 was not being provided the medication as prescribed. Records show one medication that was received on 2/5/2024 and facility documented on their Centrally Stored Log (CST) that the resident started to take that particular medication on 2/10/2024. The total quantity received was 600 pills and as of today 3/15/2024 resident had 4 bottles still closed and the only bottle that was observed open still had all medication.
Continue report see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
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 21-AS-20240215083304
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/15/2024
NARRATIVE
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 Continue report from LIC9099

There was additional medication that had too many pills in the container and facility has no documentation to explain why R1 has too much based on the medication count of when medication was started or is missing medication in their box.

Based on LPAs medication count and review of records the allegation for Staff do not distribute residents' medications as prescribed is found to be SUBSTANTIATED. A finding that the allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240215083304
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2024
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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Facility to send in written statement on how they will stay in compliance and assist residents correctly with their medications. Facility to provide
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This requirement was not met, As evidenced by: Based on medication count for R1, some medication bottles had too much medication left or were missing medication. This is an immediate risk to the Health & Safety of residents in care.
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proof ALL staff have received medication training and confirm they have reviewed and all medication is properly documented in the centrally stored log. POC for written statement due 3/19/24, Proof of staff training due 3/25/24 and medication audit/log due 3/29/24 to LPA A Canela
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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: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3