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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803953
Report Date: 03/21/2023
Date Signed: 03/21/2023 04:33:06 PM

Document Has Been Signed on 03/21/2023 04:33 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:
03/21/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Dante Ward, AdministratorTIME COMPLETED:
04:43 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Case Management - Annual Continuation inspection and met with Dante Ward, Licensee and Administrator. The purpose of this visit is to review additional items that were not completed during the annual inspection on 03/07/2023.

LPA observed hygiene supplies, hand soap and paper towels available in bathrooms. Food supply was within regulation. Client medication was centrally stored. LPA discussed regulation 80075(k)(5) with administrator. Bedrooms were furnished per regulation. Staff records were reviewed during this visit; staff have cardiopulmonary resuscitation (CPR) training and first aid training completed.
LPA reviewed client's facility files and observed 3 of 4 clients with their LIC 602 Physician's Report to be missing. LPA requested client's to be evaluated by their primary physician and to complete the LIC 602 as required. Copies of LIC 602's to be submitted to Community Care Licensing.


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: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2023
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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