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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800855
Report Date: 06/02/2022
Date Signed: 06/02/2022 02:34:02 PM

Document Has Been Signed on 06/02/2022 02:34 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 IVFACILITY NUMBER:
486800855
ADMINISTRATOR:SALVADOR, MARIAFACILITY TYPE:
740
ADDRESS:333 FORESTHILL DRIVETELEPHONE:
(707) 731-0803
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 5DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lolita Pementel, House ManagerTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with House Manager, Lolita Pementel (LP).The facility currently provides care for five (5) residents some of which with a diagnosis of dementia.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with House Manager, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 3/30/2022 at the time of the visit. There was a sufficient supply of 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. Toxins are stored securely in designated staff quarters and garage. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. LPA tested smoke alarms and were all found to be in working order. Medication is stored in a secured cabinet located in the kitchen. Hot water measured between 105.9 and 107.7 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by residents. LPA also confirmed that all staff have updated 1st Aid & CPR Training on file.

During the inspection LPA observed two residents (R1 & R2) to be under the age of 65. LPA conducted a file review, interviewed House Manager and resident R1 and found the level of care to be compatible with the other residents. In addition, staff are able to meet all care needs for all residents at this time.


Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HIGHLANDS CARE HOME IV
FACILITY NUMBER: 486800855
VISIT DATE: 06/02/2022
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LPA requested the following documents be sent to CCL by COB 6/9/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance

Infection Control:
Facility has submitted a mitigation program plan which has been approved. All staff and residents have been fully vaccinated and boosted with no reported or observed symptoms. Posters have been placed at the front door, and facility has a station at main entrance with a sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and residents are screened on a daily basis.

No deficiencies were cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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