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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800855
Report Date: 05/29/2024
Date Signed: 05/29/2024 02:48:52 PM

Document Has Been Signed on 05/29/2024 02:48 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/
DIRECTOR:		SALVADOR, MARIAFACILITY TYPE:
740
ADDRESS:333 FORESTHILL DRIVETELEPHONE:
(707) 731-0803
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Lolita Pimentel, House ManagerTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection and to deliver findings to a complaint investigation.
LPA was allowed entry by House Manager Lolita Pimentel. The facility currently provides care for six (6) residents, one (1) is receiving hospice services. Three (3) of the residents were attending Day Program at the time of inspection and the other three (3) were on site.

LPA toured the facility with House Manager; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Residents' bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 3/28/2024. 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 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 109 degrees F and 111 degrees F in the two (2) bathrooms which is within Title 22 regulations of 105 to 120 degrees F in faucets used by residents.
Continued on 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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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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: 05/29/2024
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Continued from 809.....

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 5 out of 5 staff had the required annual training. Last training was conducted in March 2024. 5 out of 5 client files were found to be complete.

LPA requested the following documents:

LIC500
Resident Roster


No deficiencies were found at the time of inspection.
No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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