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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320369
Report Date: 07/26/2024
Date Signed: 07/26/2024 03:56:58 PM

Document Has Been Signed on 07/26/2024 03:56 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:HIGHMORE CARE HOMEFACILITY NUMBER:
198320369
ADMINISTRATOR/
DIRECTOR:		GUIAO, JOSEFINAFACILITY TYPE:
735
ADDRESS:29306 S. HIGHMORE AVETELEPHONE:
2138801627
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 4CENSUS: 4DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH:Josefine Guiao, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:13 PM
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On 07/25/2024 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA was met by Arnold and Kris Gomez volunteers and later by Josefine Guiao, Administrator (S1) and Karen Bishops, Assistant Administrator (S2), and the purpose of the visit was explained.

The facility is licensed as an Adult Residential Facility, to serve four (4) ambulatory clients aged 18-59 years, of which three (3) may be non-ambulatory clients. The facility is a single-story home, located in a residential neighborhood, which consists of the following: four (4) bedrooms, two (2) full bathrooms and a one-half ( ½ ) bathroom. The client bedrooms are furnished with required bedding, tables, chairs, dressers, closets, and lamps, all of which contain sufficient lighting. Mattresses were in good condition, adequate lighting, plenty of dresser and at least eight (8) cubic feet of closet space was observed. Walls and floors were clean and in good condition. LPA observed a sufficient supply of linens, toiletries, bath towels stored in each client bedroom closet and laundry room cabinets and all four (4) bedrooms are located near the front entrance in the home. All bathrooms have a working toilet, wash basin and shower with non-slip mats and no mold was observed in the showers. All bathrooms have working fixtures and one bathroom is designated for non-ambulatory adult(s) and the facility has a tankless water heater which delivers hot water as follows: Kitchen water was measured at 108.9 degrees F, bathroom number one (#1) at 107.8 degrees F and bathroom two (#2) was measured at 108.3 degrees F, while bathroom number three (#3) could not be measured due to the motion-sensor faucet. The facility kitchen, living room, and (2) dining areas are part of an open floor plan. The laundry room and ½ bathroom are in the rear area of the home. There is also a detached, two (2) car garage, that is being utilized as a storage area and staff office. The back yard has a covered patio with table and chairs accessible to clients. The back yard also has a deck with additional seating and a table. LPA toured the backyard and observed all passageways are clear of obstruction.
The facility has one (1) accessible fire extinguisher with annual-maintenance tag dated as 10/19/2023, which is fully charged. Report continues, see LIC809C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HIGHMORE CARE HOME
FACILITY NUMBER: 198320369
VISIT DATE: 07/26/2024
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The kitchen was inspected, and sufficient two (2) days of perishable and seven (7) days of non-perishable food was maintained adequately. LPA observed secured storage area for chemicals, centrally stored medications, and sharp objects located under the kitchen island. The facility has one (1) carbon monoxide detector and eight (8) dual-functioning smoke/carbon monoxide detectors, wired and connected, all in working condition. LPA observed required postings are visible in the dining area.
LPA observed First Aid Kit was properly maintained. A working landline phone was operational. . The facility has current liability insurance on file, effective 08/10/2024 through 08/10/2024.

An audit of two (2) residents (R2-R3) service files and three (3) staff (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Josefina Guiao #7032619735, valid through 12/09/2024.

There has been one (1) deficiency cited during today's visit, see LIC809D. There have been three (3) Technical Advisory Notes - Technical Violation provided, please see LIC9102AN-TV(s)

An exit interview was held with Josefina Guiao, Administrator, and a copy of this report, facilities' appeal rights, have been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/26/2024 03:56 PM - It Cannot Be Edited


Created By: Mario Leon On 07/26/2024 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HIGHMORE CARE HOME
FACILITY NUMBER: 198320369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in not having conducted their quarterly drill since initially licensed on 07/14/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2024
Plan of Correction
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Administrator and LPA have agreed that the next quarterly drill will be conducted on, or prior to, the POC due date which is 07/30/2024 and that a copy of the quarterly drill will be scanned and sent to LPA, via email, to Mario.Leon@DSS.CA.GOV
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
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