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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803953
Report Date: 03/07/2023
Date Signed: 03/07/2023 05:01:40 PM

Document Has Been Signed on 03/07/2023 05:01 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HIGH POINTE RESIDENCESFACILITY NUMBER:
486803953
ADMINISTRATOR:WARD, DANTEFACILITY TYPE:
735
ADDRESS:1737 YORK ST.TELEPHONE:
(707) 712-8038
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
03/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Dante Ward, AdministratorTIME COMPLETED:
05:12 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Dante Ward, Licensee and Administrator. LPA toured the facility, all exits were unobstructed, and observed a COVID-19 screening station. Fire extinguisher was charged and serviced 02/22/2023. The facility has a supply of PPE. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. There are 6 smoke detectors & 1 carbon monoxide detector, which were tested & observed operational.

Due to time constraint, LPA will return at a later date to complete the inspection tool kit and issue citations if warranted.

LPA requested the following updated forms to be submitted to Community Care Licensing by 04/07/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· LIC 9282 Infection Control Plan
· Copy of Surety Bond
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Administrator's Certificate
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Administrator, whose signature on this document confirms receipt. No deficiencies cited.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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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