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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486800855
Report Date: 04/28/2025
Date Signed: 04/28/2025 03:23:49 PM

Document Has Been Signed on 04/28/2025 03:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HIGHLANDS CARE HOME IVFACILITY NUMBER:
486800855
ADMINISTRATOR/
DIRECTOR:		SALVADOR, MARIAFACILITY TYPE:
740
ADDRESS:333 FORESTHILL DRIVETELEPHONE:
(707) 731-0803
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 6CENSUS: 6DATE:
04/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Christine Salvador, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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At approximately 12:50 PM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Caregiver. Administrator Maria Salvador was unavailable and Assistant Administrator (AA) Christine Salvador was sent to sign report. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. At time of visit, three (3) residents were present with the rest at day program. Facility has a Dementia Care Plan, a Hospice waiver for one (1), with zero (0) Hospice residents currently in care, and is approved for all non-ambulatory residents.

At approximately 1:15 PM, LPA initiated a tour of the facility with Caregiver and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 3/25. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperature measured 112.4 degrees F and 105.9 degrees F, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked.

LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered, as well as an emergency water supply. There is a seating area in the backyard with outdoor space for activities. LPA observed one locked shed in the backyard which acts as additional storage. Facility has an internet access device designated for resident use and internet service available. Facility telephone was tested and operational during inspection.
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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HIGHLANDS CARE HOME IV
FACILITY NUMBER: 486800855
VISIT DATE: 04/28/2025
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Continued from 809...


At approximately 2:00 PM LPA conducted a review of three (3) resident records. All required documentation present.

At approximately 2:30 PM LPA conducted review of three (3) staff records. All required documentation present.

At approximately 2:45 PM LPA and Caregiver conducted a spot check of medication and medication records. Medication is centrally stored and locked.

Maria Salvador Administrator Certificate 7004161740 expires 3/21/2026. All fees are current as of this time.



LPA and Administrator discussed facility's Emergency Disaster plan, last updated 2/25. Facility’s last quarterly disaster drill was conducted on 10/24.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

Liability Insurance
LIC500 - Personnel Report
LIC308 - Designation of Responsibility
LIC400 - Affidavit Regarding Client Cash Resources
LIC610D - Emergency Disaster Plan

No deficiencies cited. Exit interview conducted with Administrator and a copy of this report was given.

Exit interview conducted with Assistant Administrator and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC809 (FAS) - (06/04)
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