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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800160
Report Date: 10/16/2025
Date Signed: 10/16/2025 02:58:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2022 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221117103535
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: 93DATE:
10/16/2025
UNANNOUNCEDTIME BEGAN:
07:36 AM
MET WITH:Melissa Villafana - Manor Coordinator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not consult responsible party regarding a resident's care
Staff do not distribute resident's medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Melissa Villafana and explained the reason for the visit.

The investigation consisted of the following: On 11/22/22 LPA Nwogene conducted an initial complaint investigation visit. On 10/13/25 LPA contacted facility’s administrator and requested copies of resident #1(R1)’s physician’s report, needs and care plan, emergency and information sheet, vaccine records, facility’s mitigation plan and infection control plan. On 10/14/25 LPA Flores conducted interviews with 5 staff over the phone. On 10/16/25 LPA Flores conducted interviews with 8 residents and reviewed medication for 9 residents and collected the documents previously requested, admission agreement, medication records for August – November of 2022, and chart notes for September – November 2022 for R1. LPA delivered findings.
(CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 18-AS-20221117103535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HIGHGATE SENIOR LIVING-TEMECULA
FACILITY NUMBER: 331800160
VISIT DATE: 10/16/2025
NARRATIVE
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The investigation revealed the following: Regarding allegation: Staff did not consult responsible party regarding a resident's care. It is alleged resident’s responsible party was not contact before giving R1 a vaccination dosage during facility’s vaccination clinic day. Interviews with residents revealed 5 out of 8 residents stated facility staff either contact responsible party before medical decisions or believe that it will happen. 1 out of 8 residents did not know if the facility staff will contact their responsible party. 1 out of 8 residents is able to make decisions for self, therefore responsible party will not be contact, and 1 out of 8 residents was unable to answer due to cognitive skills. Interviews with staff revealed staff contact responsible party when offering a vaccination clinic to obtain either a release form or verbal approval from residents' responsible party prior clinic day to provide any vaccinations. Documents reviewed reveal, R1 had a durable power of attorney signed on 4/8/11 which notes that if there are other matters other than those listed on POA, the POA is able to make decisions for R1. Per R1’s physician’s report dated; 9/19/22, R1 was noted with dementia. There were no records that R1’s responsible party signed consent for vaccination clinic on 11/16/22. Therefore, this allegation is SUBSTANTIATED.

Regarding allegation: Staff do not distribute resident's medication as prescribed. It is alleged resident’s medication was not distributed appropriately. Interviews conducted with residents revealed 7 out of 8 residents stated facility staff provides medications as needed. 1 out of 8 residents handles own medications. 5 out of the 8 residents stated that they are provided as needed medications when requested. Interviews with staff revealed staff centrally stored medications for residents that are on medication assistance, including medication that may be brought by the responsible party. Per staff once the medication is provided it is labeled with residents’ name and it is only used for that resident. Documents reviewed for R1 note R1 was provided with medications as prescribed between August and October of 2022. Medication review conducted on 10/16/22 revealed the following residents were missing the following as needed/routine medications; resident #2(R2) anti-acid liquid, resident#3(R3) acetaminophen 325mg and 500mg, anti-acid liquid, antifungal 2% powder, benzonatate 100mg, fexofenadine 180mg, loperamide 2mg, ondansetron 4mg. Resident #4(R4) acetaminophen 325mg, anti-acid liquid, baqsimi 3mg spray, bysacodyl 10mg suppository, fleet enema, loperamide 2mg, milk of magnesia, naloxone 4mg spray, robafen 10/100mg. Resident #5(R5) chlorhexidine 4% was observed and was noted as discontinued on medication sheet and Mucinex 1200mg observed and not listed on medication sheet, memory armor 300mg(routine medication), anti-acid liquid, ibuprofen 200mg, loperamide 2mg, milk of magnesia, quetiapine fumarate 25mg, Resident #6(R6) baza moisture cream, hydrocodone/APAP 5/235mg, senna 8.6mg, loperamide 2mg was observed and has been discontinued since 5/1/25. (CONTINUED ON LIC 9099C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20221117103535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HIGHGATE SENIOR LIVING-TEMECULA
FACILITY NUMBER: 331800160
VISIT DATE: 10/16/2025
NARRATIVE
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Resident #7(R7) ivermectin 3mg(routine) observed and noted as discontinued on medication sheet, triamcinolone .025% cream. Resident #8(R8) anti-acid liquid, Benadryl 1-0.1 % cream, fleet enema, ondansetron 4mg, tripe antibiotic ointment, docusate sodium 2mg was observed and not listed on medication sheet. Resident #9(R9) Albuterol, geri-tussin 100mg, ibuprofen 800mg, milk of magnesia. Resident #10(R10) acetaminophen 325mg, docusate sodium 250mg, hydrocortisone 1% cream, loperamide 2mg, lubricant eye .4% drops, milk of magnesia, naloxone 4mg spray. Therefore this allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted and a copy of this report, LIC 9099C, and appeal rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20221117103535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HIGHGATE SENIOR LIVING-TEMECULA
FACILITY NUMBER: 331800160
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2025
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities : (a)Residents...care facilities for the elderly shall.. rights: (8) To have their representatives regularly informed... of... related to care or services,...
This requirement is not met as evidence by:
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Administrator will provide in-service training to staff regarding notify, and obtaining consent prior to services related to the residents in care and submit a copy of training with log that includes topic, date, and signatures by POC due date 10/17/25.
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Based on documents and interiviews conducted licensee did not ensure R1's responsible party was notified or provided consent regarding vacination clinic which poses an immediate risk to the persons safety, personal rights, and health of the persons in care.
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Type A
10/17/2025
Section Cited
CCR
87464(f)(6)
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87464 Basic Services: (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465,...
This requirement is not met as evidence by:
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Administrator will provided in-service training to medication staff, conduct an audit of medications and submit a copy of training, audit plan to the department by POC due date 10/17/25.
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Based on observation and document review licensee did not ensure R2-R10 had medications available at the faciltiy which poses an immediate risk to the health, safety, personal rights of the persons in care.
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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.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2022 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221117103535

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: 93DATE:
10/16/2025
UNANNOUNCEDTIME BEGAN:
07:36 AM
MET WITH:Melissa Villafana - Coordinator TIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not follow COVID protocol
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Melissa Villafana and explained the reason for the visit.

The investigation consisted of the following: On 11/22/22 LPA Nwogene conducted an initial complaint investigation visit. On 10/13/25 LPA contacted facility’s administrator and requested copies of resident #1(R1)’s physician’s report, needs and care plan, emergency and information sheet, vaccine records, facility’s mitigation plan and infection control plan. On 10/14/25 LPA Flores conducted interviews with 5 staff over the phone. On 10/16/25 LPA Flores conducted interviews with 8 residents and reviewed medication for 9 residents and collected the documents previously requested, admission agreement, medication records for August – November of 2022, and chart notes for September – November 2022 for R1. LPA delivered findings.
(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20221117103535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HIGHGATE SENIOR LIVING-TEMECULA
FACILITY NUMBER: 331800160
VISIT DATE: 10/16/2025
NARRATIVE
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The investigation revealed the following: Regarding allegation: Staff did not follow COVID protocol. It is alleged facility staff failed to review resident’s vaccination records, resulting in R1 receiving an additional COVID vaccine booster on 11/16/22. Interviews conducted with residents revealed residents received assistance and COVID protocols are followed. Interviews with staff revealed facility assist residents by offering a vaccination clinic yearly. Per staff, they did become aware R1 received the dose during the clinic. Facility staff contacted R1’s physician and was placed on alert checks that day. Facility records provided for review revealed R1’s physician’s report dated: 9/19/22 notes dementia. COVID 19 vaccination record notes R1 had 5th booster shot on 10/13/22 at local stored. On 11/16/22, R1 received a booster shot provided by Rons pharmacy. Per chart notes on 11/16/22 staff spoke with responsible party who acknowledge to provide care for R1 after becoming aware of booster shot given to R1. LPA was unable to interview R1 as R1 passed away on 11/25/23. LPA reviewed mitigation plan last updated on 10/31/24 and Infection control last updated on January 2016. There are no protocols regarding vaccination boosters. Although, facility staff failed to ensure R1 did not receive an additional booster shot within a month. There were no protocols or mandates regarding COVID vaccinations other than recommendations to followed. In addition, R1 was residing in the assisted living portion of the facility from 3/16/20 to 11/15/23 and because we are unable to determine whether R1 willingly participated in obtaining the shot we cannot said R1 was asked to obtained the vaccination shot by staff. Therefore, this allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6