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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800160
Report Date: 12/21/2022
Date Signed: 12/21/2022 04:10:16 PM


Document Has Been Signed on 12/21/2022 04:10 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:HIGHGATE SENIOR LIVING-TEMECULAFACILITY NUMBER:
331800160
ADMINISTRATOR:WILLIAMS, KATHLEENFACILITY TYPE:
740
ADDRESS:42301 MORAGA ROADTELEPHONE:
(951) 308-1885
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY:99CENSUS: 98DATE:
12/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:ADMINISTRATOR, KATHLEEN WILLIAMS.TIME COMPLETED:
04:15 PM
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On December 21, 2022, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced case management visit to follow up on a self reported incident. LPA Mixson met with Administrator, Kathleen and explained the purpose of the visit.

LPA Mixson toured the facility with Administrator there were no Health and/or Safety concerns observed during this visit. LPA Mixson requested and received pertinent documents.

There are no imminent health and/or safety concerns observed at the time of visit. LPA Mixson observed facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA Mixson assessed the available food supply and observed that the supply exceeds the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. Medications were found to be in sufficient supply as well.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. LPA Mixson explained to Administrator that additional time is needed to conclude the follow-up on the self reported incident.

An exit interview was conducted a copy of this report, along with LIC 811, and was provided to Administrator

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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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