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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800855
Report Date: 05/16/2023
Date Signed: 05/16/2023 01:41:13 PM

Document Has Been Signed on 05/16/2023 01:41 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: 6DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Lolita Pimentel, House ManagerTIME COMPLETED:
01:55 PM
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On 5/16/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and met with House Manager, Lolita Pementel (LP). Administrator, Christine Sandoval was contacted and arrived later in the visit. The facility currently provides care for six (6) residents none of which with a diagnosis of dementia or receiving hospice services.

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 4/3/2023 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 along with medication records. A spot medication count was conducted and both records and administration review found to be in order. Hot water measured at 106.7 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by residents.

LPA conducted a review of staff records and confirmed that all staff have updated 1st Aid & CPR Training on file. Upon review of training records, LPA found that 2 out of 3 staff require updated annual training. Last training was conducted in January 2022. Technical Violation issued. Administrator agrees to implement staff training and submit proof to CCLD.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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: 05/16/2023
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LPA conducted a full review of resident files. LPA found that 3 out of 6 residents' Needs & Service Plan are in need of updating. In addition, resident (R1) had recently been placed on oxygen use and although has proper safety requirements for use of oxygen; requires an updated Physician's Report. Administrator stated that R1 has received a physical examination within the past several weeks and will request for an updated Physician's Report. Copy of the report to be submitted to CCLD. Technical violations issued and regulation reviewed with Administrator.

Christine Salvador's Administrator Certification 6057700740 expires on 10/7/2023.


LPA requested the following documents be sent to CCL by COB 5/30/2022:

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

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

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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