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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200652
Report Date: 08/23/2019
Date Signed: 08/28/2019 11:58:50 AM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HIGH COUNTRY ELDERLY CAREFACILITY NUMBER:
019200652
ADMINISTRATOR:NADINE VILLICANAFACILITY TYPE:
740
ADDRESS:27965 HIGH COUNTRY DRIVETELEPHONE:
(510) 582-6397
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY:6CENSUS: 0DATE:
08/23/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Daisy VillicanaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and was met by Daisy Villicana. Licensee was informed via telephone about LPA's presence at the facility.

LPA was informed by Villicana that there are no residents living at the facility. Family members are currently living at the facility. LPA inspected 3 resident rooms, kitchen, living room and backyard. LPA observed all bedrooms are vacant. Passageways and hallways were observed free of obstruction. Hot water measured at 111 degrees Fahrenheit. Fire extinguisher was observed full and was last serviced on 10/4/18.

No deficiency noted for today's visit.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
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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