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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800855
Report Date: 06/29/2021
Date Signed: 06/29/2021 12:52:42 PM

Document Has Been Signed on 06/29/2021 12:52 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:HIGHLANDS CARE HOME IVFACILITY NUMBER:
486800855
ADMINISTRATOR:SALVADOR, MARIAFACILITY TYPE:
740
ADDRESS:333 FORESTHILL DRIVETELEPHONE:
(707) 731-0803
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 6DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Lolita PimentelTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Lopez and Tobola conducted an unannounced required 1 year inspection to Highlands Care Home IV and was welcomed by house manager Lolita Pimentel. Licensee Maria Salvador was contacted but unavailable during the visit. There are 6 residents in the facility some of which have a diagnosis of dementia. No residents currently on hospice.

LPAs continued tour of the facility on June 29th, 2021 with house manager Lolita Pimentel. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPAs observed two staff not wearing masks and were asked to wear masks on a daily basis for resident's health and safety. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on April 8th, 2021 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. There was sufficient amount of supply for both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. LPAs observed unsecured cleaning supply underneath kitchen sink, which was immediately secured and locked away in garage cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available.



No deficiencies observed or cited during today's Required 1- Year inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
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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