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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486800855
Report Date: 05/29/2024
Date Signed: 05/29/2024 02:01:52 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/09/2024 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20240509122719
FACILITY NAME:HIGHLANDS CARE HOME IVFACILITY NUMBER:
486800855
ADMINISTRATOR:SALVADOR, MARIAFACILITY TYPE:
740
ADDRESS:333 FORESTHILL DRIVETELEPHONE:
(707) 731-0803
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:6CENSUS: 6DATE:
05/29/2024
UNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Lolita Pimentel, House ManagerTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff do not safeguard resident's cash resources
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to deliver findings for complaint 21-AS-20240509122719 at Highlands Care Home IV on 05/29/2024. LPA met with Lolita Pimentel, House Manager.

The complaint alleges that Staff do not safeguard resident's cash resources. During the investigation, LPA verified that Client (C1) is able to manage their own cash resources. LPA reviewed records, conducted interviews and made observations. Upon review of the evidence, the Department found that an individual not employed with the facility had access to/possession of C1’s EBT card.
Continued 9099-C...


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
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 2
Control Number 21-AS-20240509122719
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HIGHLANDS CARE HOME IV
FACILITY NUMBER: 486800855
VISIT DATE: 05/29/2024
NARRATIVE
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Continued from 9099....

It was reported to the facility and county officials that C1’s funds were reduced while not in C1’s possession. It was later learned that the alleged abuse occurred by an outside individual and not facility staff who had obtained the EBT card without facility or staff knowledge.

Therefore, due to the facility staff not having possession, control or access to the EBT card, and C1 able to manage their own cash resources, the allegation that Staff do not safeguard the resident’s cash resources 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2