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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803953
Report Date: 03/28/2024
Date Signed: 03/28/2024 12:29:04 PM

Document Has Been Signed on 03/28/2024 12:29 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: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:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Dante WardTIME COMPLETED:
12:38 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Administrator Dante Ward. House Manager Marcel Love was also present during visit.

This facility has a fire clearance for four ambulatory residents. There are four private resident rooms and one has a full private bathroom. There is one full common bathroom. There is an ample supply of perishable and nonperishable food. The backyard was inspected. There is a locked shed in the backyard.

Multiple topics were discussed.

The following shall be updated and submitted to Community Care Licensing Division by April 17, 2024:
-LIC 308 designation of administrative responsibility
-current liability insurance
-LIC 500 facility personnel or staff schedule

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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