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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800554
Report Date: 03/15/2024
Date Signed: 03/18/2024 02:08:28 PM

Document Has Been Signed on 03/18/2024 02:08 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
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: 6DATE:
03/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Francesca Cristobal, care staff and Lolita Pimentel, care staffTIME COMPLETED:
05:23 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced and met with care staff, Francesca Cristobal and Lolita Pimentel arrived towards the end of the visit. Administrator is out of the country and not available.

During a complaint investigation and in review of staff training records, staff S2 has been providing medication assistance and has no proof of medication training. Staff S1 was missing 2 additional hours of medication training and S2 did not have all of the required training in the areas required.

LPA requested facility to provide an updated medical assessment for R2 who shows as being ambulatory but R2 is using a walker.
In addition, facility does not have the required size PUB475 and facility was advised to get and post the correct poster size, failure will result in the facility being cited.
LPA also found some incident reports for R1 but the facility was unsure if the reports were sent to Community Care Licensing (CCL). It was also disclosed that R1 moved and were not sure if R1 left on their own or if the facility evicted R1.

LPA will review facility file to ensure CCL was notified, failure to show that the facility notified CCL will result in the facility being cited for failure to report within the required time. LPA will also review if a 30 day eviction was properly issued to R1 and a copy sent to CCL.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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Document Has Been Signed on 03/18/2024 02:08 PM - It Cannot Be Edited


Created By: Araceli Canela On 03/15/2024 at 05:33 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
, 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 B
03/29/2024
Section Cited
CCR
87412(c)

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87412(c) Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
This requirement was not met.
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Facility to send in proof of required training and training certificates for staff. Facility to send in written statement they understand requirement and how they will ensure they stay in compliance.
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As evidenced by: during review of medication, LPA discovered staff did not have proof of required training. This is a potential risk to the health and Safety of residents in care.
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POC due date for staff training due 3/29/2024 Attention 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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