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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800554
Report Date: 02/12/2025
Date Signed: 03/06/2025 09:25:54 AM

Document Has Been Signed on 03/06/2025 09:25 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HIGHLANDS CARE HOME III, THEFACILITY NUMBER:
486800554
ADMINISTRATOR/
DIRECTOR:		MARIA M. SALVADORFACILITY TYPE:
740
ADDRESS:349 AUBURN DR.TELEPHONE:
(707) 644-7923
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Christiane Salvador, Designated Responsible Party TIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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*Amended to Correct Facility Name.
At approximately 1:30 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and was greeted by Caregiver Leonida Arinzana. Facility Administrator Maria Salvador was not available for the Inspection. Designated Responsible Party (DRP), Christiane Salvador arrived at 1:45 PM. Highlands Care Home III, is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for five (5) non-ambulatory residents and one (1) ambulatory resident. The facility has a Hospice Waiver for two (2) residents. Upon arrival, LPA was informed that there were five (5) residents in care and one (1) staff members on-site. At approximately 1:50 PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 2:00 PM, LPA toured the facility with Administrator Salvador. All exits were clear and unobstructed. Fire extinguisher were last serviced and tagged in 3/2024. Fire Department inspected and cleared the fire alarm system in 1/2024. Food supply was sufficient. The facility was sufficiently lighted. LPA inspected four (4) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted on 11/2/2024. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and operational.
Continued on 809-C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HIGHLANDS CARE HOME III, THE
FACILITY NUMBER: 486800554
VISIT DATE: 02/12/2025
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...Continued from 809

At approximately 2:50 PM, LPA reviewed four (4) resident files. Four (4) of four (4) resident files were found to have all required documentation. LPA reviewed four (4) staff files. One (1) staff file (S2) was observed to have a medical assessment and Tuberculosis test that was dated prior to six (6) months before employment. This deficiency will be cited. Four (4) of four (4) staff files were observed to have First Aid and CPR certification. Four (4) of four (4) staff files were observed to lack proper training documentation. This deficiency will be cited. LPA spot checked Medication for three (3) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. The facility does not handle resident’s monies for personal and incidental items. The Facility does not have an internet access device. This deficiency will be cited.

Maria Salvador’s Administrator Certification 7004161740 is current with an expiration date of 3/21/2026.

LPA requested the following documents be submitted to Community Care Licensing by 3/12/2025:



LIC 500 Personnel Report
LIC 308 Designation of Responsibility
LIC 610D Emergency Disaster Plan
Updated Lease
Proof of Liability Insurance

Exit interview conducted with Caregiver Leonida Arinzana. Copy of report, LIC809Ds (Deficiency Pages) with plans of corrections, Confidential Names (LIC811), and Appeal Rights discussed and provided to caregiver Arinzana. Signature on form confirms receipt of documents
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/12/2025 04:57 PM - It Cannot Be Edited


Created By: Robert Frank On 02/12/2025 at 04:24 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: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that one (1) staff member (S2) was observed to have a medical assessment and Tuberculosis test that was dated prior to six (6) months before employment] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Administrator or Designated Responsible Party will submit to Community Care Licensing a current medical assessment and Tuberculosis test for staff member S2 by POC due date of 2/14/2025.

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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/12/2025 04:57 PM - It Cannot Be Edited


Created By: Robert Frank On 02/12/2025 at 04:24 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: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that four (4) of four (4) staff files for S1, S2, S3, S4 were observed to lack proper training documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Administrator or Designated Responsible Party will submit to Community Care Licensing proof that staff members S1, S2, S3 and S4 have began their 20 hours of required annual training by POC due date of 3/5/2025.
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that at least one internet access device was dedicated and available for client use, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Administrator or Designated Responsible Party will self certify that at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with video conferencing technology, including microphone and camera functions, and is dedicated for client use is on the facility premises by POC due date of 3/12/2025
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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