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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426762
Report Date: 01/19/2024
Date Signed: 01/19/2024 02:05:27 PM

Document Has Been Signed on 01/19/2024 02:05 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
, CA 92507
FACILITY NAME:HIGHLAND SENIOR HOME CARE LLCFACILITY NUMBER:
366426762
ADMINISTRATOR:LIWANAG, AMPAROFACILITY TYPE:
740
ADDRESS:7513 SWEETMEADOW COURTTELEPHONE:
(909) 714-0225
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 6CENSUS: 5DATE:
01/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Pat Salinas, care providerTIME COMPLETED:
02:09 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to conduct a required annual inspection. LPA was met by care provider Pat Salinas who was informed of the purpose of the visit. SAlinas phoned Licensee Amparo Liwanag and spoke with LPA. LPA informed Licensee of the reason for LPA's visit. LPA and Salinas toured the interior and exterior of the facility. The facility is licensed for 6 non-ambulatory residents with a hospice waiver for three (3).

Physical Plant and Safety of Environment/Operational Requirements: LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature was measured and found to be comfortable for residents. Laundry facilities and locked cabinets were present for storing laundry soap and other chemicals. Fire extinguishers are charged. All outdoor and indoor passageways and ramps are free of obstruction. The facility does not have bodies of water. A locked area is provided for medications and sharp objects. There is a working telephone at this location. The LIC 610E, emergency disaster plan is maintained. The facility is maintained in conformity with the regulations adopted by the state fire marshal.

Personnel Records/Training/and Staffing: LPA reviewed employee records for fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. LPA did not observe training on needs for residents receiving hospice services. This poses a potential health and safety concern for clients in care.
Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental: LPA reviewed resident records and found that they contained records including, admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, safeguard for personal property/valuables, and personal rights notification. The facility is meeting documentation requirements. Resident Rights are posted in the facility and a copy is signed on file. During the visit, LPA and staff observed Resident 1 (R1) non-prescription
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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Document Has Been Signed on 01/19/2024 02:05 PM - It Cannot Be Edited


Created By: Anna Bueno On 01/19/2024 at 12:38 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HIGHLAND SENIOR HOME CARE LLC
FACILITY NUMBER: 366426762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, staff interview, resident record review, the licensee did not comply with the section cited above as Resident 1 (R1) was observed with nonprescription medication without a physician's order, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Licensee shall maintain a physician's order for R1's prescription and nonprescription PRN medication. Licensee shall submit proof of correction to the Department no later than end of POC date.
Type B
Section Cited
HSC
1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and 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 LPA observation and staff interview, the licensee did not comply with the section cited above as Licensee did not have documentation of conducted disaster drills which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Licensee shall maintain a documentation of the disaster drills as stated in regulation. Proof of correction shall be submitted to the Department no later than end of POC date.
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:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/19/2024 02:05 PM - It Cannot Be Edited


Created By: Anna Bueno On 01/19/2024 at 12:38 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: HIGHLAND SENIOR HOME CARE LLC
FACILITY NUMBER: 366426762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations and resident records review, the licensee did not comply with the section cited above as Resident 2 (R2) bed was observed with full bed rails, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Licensee shall remove full bed rails from R2's bed. Proof of compliance shall be submitted to the Department no later than end of POC date.
Type B
Section Cited
CCR
87633(f)(1)
Hospice Care for Terminally Ill Residents
(1) The record of each training session shall specify the names and credentials of the trainer, the persons in attendance, the subject matter covered, and the date and duration of the training session.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above in that neither staff nor hospice records show training received by facility staff regarding the needs of residents receiving hospice services, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Licensee shall provide training regarding the needs of residents receiving hospice services. Proof of compliance shall be submitted to the Department no later than end of POC date.
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:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


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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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: HIGHLAND SENIOR HOME CARE LLC
FACILITY NUMBER: 366426762
VISIT DATE: 01/19/2024
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PRN medication without a physician's order. This poses a potential health and safety risk to clients in care.

Food Service: LPA Bueno was present during lunch time. LPA observed the meal is adequate to meet the nutritional needs of the residents. Food supply meets the requirement of one week supply of nonperishable and 2-day supply of perishables food on hand. The kitchen area is kept clean.

LPA Bueno made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors were tested by staff while LPA Bueno tested the hallway carbon monoxide detector. All units were found to be operational.

During today's visit, LPA found Resident 2 (R2) with full bed rails and was not receiving any home health or hospice services. LPA was also informed that there is no documentation for disaster drills available. These pose potential health and safety risks to clients in care.

Based on the information received during this visit today, the following deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. Refer to LIC 809D for cited deficiencies. This report and LIC 809D were reviewed by phone wiht Licensee Liwanag and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC809 (FAS) - (06/04)
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