<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006372
Report Date: 08/28/2024
Date Signed: 08/28/2024 03:33:09 PM


Document Has Been Signed on 08/28/2024 03:33 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HIGHTOWER RESIDENTIAL CAREFACILITY NUMBER:
306006372
ADMINISTRATOR:ARONNE, CELFAFACILITY TYPE:
740
ADDRESS:23391 CAVANAUGH ROADTELEPHONE:
(949) 500-3760
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 3DATE:
08/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Norma AronneTIME COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Kimberly Lyman and Sam Haddadin conducted an unannounced case management in-conjunction with complaint #22-AS-20240821154034. LPAs were greeted and granted entry into the facility and explained the reason for the visit.

During the course of the complaint investigation, LPA interviewed Administrator and witness. Witness indicates the admission agreement/ file for Resident 1 was requested on or about 08/12/2024. The records were produced by facility on 08/20/2024.










Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/28/2024 03:33 PM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: HIGHTOWER RESIDENTIAL CARE
FACILITY NUMBER: 306006372

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2024
Section Cited
CCR
87507(e)

1
2
3
4
5
6
7
The licensee shall provide a copy of the signed and dated current admission agreement.. to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification...This requirement is not being met as evidenced by:
1
2
3
4
5
6
7
Licensee to forward a statement of understanding of the regulation and forward proof to LPA by POC due date.
8
9
10
11
12
13
14
Based on interviews conducted, licensee failed to ensure an admission agreement was provided to resident/ responsible party immediately after signing. This poses a potential health and safety risk to residents in care,
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2