197608079-2-25-2025-28-AS-JVIS-DE8QPM-20250225112057

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608079
Report Date: 02/25/2025
Date Signed: 02/25/2025 11:21:43 AM

Document Has Been Signed on 02/25/2025 11:21 AM - 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	HEIGHTS SENIOR CARE, THE		FACILITY NUMBER:	197608079
ADMINISTRATOR/ DIRECTOR:	SAYDA NAZ HAI		FACILITY TYPE:	740
ADDRESS:	690 PICAACHO DRIVE		TELEPHONE:	(562) 228-3063
CITY:	LA HABRA HEIGHTS	STATE: CA	ZIP CODE:	90631
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	02/25/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Administrator Sayda Naz Hai		TIME VISIT/ INSPECTION COMPLETED:	11:35 AM

NARRATIVE

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Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Sayda Naz Hai. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was observed

Physical Plant/Environment Safety:

Facility is in a residential neighborhood and is two stories home, first floor consist of a kitchen, living room, family room, 3 resident rooms, 2 bathrooms, 1 staff room, an attached garage. The Basement is the administrator's residential area and inaccessible to the residents.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard. Cleaning supplies and toxic substances are inaccessible.
Water temperature readings measured within title 22 regulations.

Operational Requirements:

A current Plan of Operation observed. Dementia Care Plan on file
A fire clearance for total 6 residents of which (5) may be Non ambulatory and (1) bedridden
Hospice care waiver approved for up to three (3) residents.

Personnel Records - Staff Training:

Administrator on file is current
Staff have criminal background clearances.
Three (3) staff files were reviewed.

Continued on LIC 809-C

Fernando Fierros	TELEPHONE: (323) 981- 3981
Jose Villalobos	TELEPHONE: (323) 980-4939
	DATE: 02/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

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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Document Has Been Signed on 02/25/2025 11:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HEIGHTS SENIOR CARE, THE	FACILITY NUMBER: 197608079
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as (5) of (5) resident medications were removed from their packaging and placed in weekly containers which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2025
	Plan of Correction
1 2 3 4	Licensee to schedule medication management training and provide LPA with date of training by POC due date. Once training is completed, Licensee to provide proof to LPA of training completion with names of staff who participated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Fernando Fierros	TELEPHONE: (323) 981- 3981
Jose Villalobos	TELEPHONE: (323) 980-4939
	DATE: 02/25/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/25/2025 11:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HEIGHTS SENIOR CARE, THE	FACILITY NUMBER: 197608079
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as (1) of (5) resident files was missing a medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/11/2025
	Plan of Correction
1 2 3 4	Administrator to aquire physicians report for resident #5 and provide to LPA by POC due date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Fernando Fierros	TELEPHONE: (323) 981- 3981
Jose Villalobos	TELEPHONE: (323) 980-4939
	DATE: 02/25/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HEIGHTS SENIOR CARE, THE	FACILITY NUMBER: 197608079
	VISIT DATE: 02/25/2025

NARRATIVE

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Staffing:

Sufficient staff observed during visit

Resident Records - Incident Reports:

A total of five (5) resident files were reviewed.

Resident Rights - Information

Required postings observed

Food Service:

Sanitation practices and kitchen cleanliness was observed.
Kitchen has utensils for clients to use and to store their meals

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.

Incident Medical and Dental:

First Aid Kid observed
(5) of (5) Resident medications reviewed

Disaster Preparedness:

Emergency and Disaster Plan observed
Last Emergency Drill conducted 12/1/24.

Residents with Special Health Needs:

Currently (2) residents receiving hospice services. Hospice care plans observed

Inspection Tool was completed and per Title 22 deficiencies are being cited on todays visit. See 809-D pages attached

Exit interview conducted. Copy of this report and appeal rights were discussed and provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC809 (FAS) - (06/04)

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