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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880503
Report Date: 05/30/2023
Date Signed: 05/30/2023 11:02:50 AM

Document Has Been Signed on 05/30/2023 11:02 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HIGHPOINTE CARE - NORTH LAKEFACILITY NUMBER:
331880503
ADMINISTRATOR:STEWART, REUBENFACILITY TYPE:
735
ADDRESS:29332 NORTH LAKE DRIVETELEPHONE:
(562) 682-0946
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 4DATE:
05/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Co-Administrators- Alexandria Silva and Maureen SevillaTIME COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit for a required annual inspection. Facility is an Adult Residential Facility licensed for four (4) ambulatory clients. LPA met with Co-Administrators (CA’s) Maureenjane Sevilla and Alexandria Silva.
LPA toured the facility inside and out. Outdoor and indoor passageways were kept free of obstruction. The facility has charged fire extinguishers, operating fire alarm systems, and carbon monoxide detectors. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. LPA toured the client bedrooms. The client bedrooms had the required furniture and functional lighting. The facility had a supply of additional towels, however did not have extra linen for the clients. CA’s stated the extra linen is stored at another nearby facility. LPA issued a technical assistance. The facility had a complete first aid kit available and the last disaster drill was conducted on 5/1/2023. Cleaning supplies, medications, and sharps were kept locked and inaccessible to the clients. LPA toured the client bathrooms. The hot water temperature measured above the required limits at 132 degrees Fahrenheit. CA’s adjusted the water heater, however water temperature did not reduce. CA’s agree to post a “Caution, Hot water” sign. The outside of the facility has a shaded area for clients in care. The facility does not have bodies of water.
LPA observed the required policies, postings and signs in a common area. LPA noted the emergency and disaster plan(LIC 610D) had not been updated since 2018. Deficiency issued. LPA reviewed staff and client files. Staff files had the required documentation including a health screening report and first aid/CPR certification. LPA reviewed the Administrators file. LPA discovered HIV/TB training had not been filed and/or completed. Deficiency issued. Client files were reviewed and had the required documentation including an admission's agreement, updated physician's reports, and appraisal/needs & services plans. LPA reviewed the Infection Control plan, which was current and up to date. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. Licensee has secured each consumer’s personal property and cash resources. Sufficient staff are employed and present in the facility to meet the needs of the consumers in care.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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 6
Document Has Been Signed on 05/30/2023 11:02 AM - It Cannot Be Edited


Created By: Victoria Chitgian On 05/30/2023 at 10:43 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HIGHPOINTE CARE - NORTH LAKE
FACILITY NUMBER: 331880503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the hot water temperature in the client bathroom measured 132 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Licensee will adjust the water heater to obtain water temperature within required limits, and submit proof of correction to CCLD via photo/email by POC due date above.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as the Administrator did not have a current HIV and TB training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2023
Plan of Correction
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Administrator will submit training completion, or training enrollment confirmation to CCLD via email by POC due date above.
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:Efren Malagon
LICENSING EVALUATOR NAME:Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 05/30/2023 11:02 AM - It Cannot Be Edited


Created By: Victoria Chitgian On 05/30/2023 at 10:43 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: HIGHPOINTE CARE - NORTH LAKE
FACILITY NUMBER: 331880503

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above as the LIC 610D has not been updated since 2018, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Licensee will update the LIC 610D and submit proof to CCLD via email, by POC due date above.
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:Efren Malagon
LICENSING EVALUATOR NAME:Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023


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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HIGHPOINTE CARE - NORTH LAKE
FACILITY NUMBER: 331880503
VISIT DATE: 05/30/2023
NARRATIVE
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 Three (3) deficiencies and two(2) technical assistance were issued during todays visit. An exit interview was conducted where this report, LIC 809, LIC 9102, and appeal rights was discussed and provided to the CA’s Maureen Sevilla and Alexandria Silva at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC809 (FAS) - (06/04)
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