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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803953
Report Date: 03/11/2025
Date Signed: 03/11/2025 02:08:21 PM

Document Has Been Signed on 03/11/2025 02:08 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/
DIRECTOR:		WARD, DANTEFACILITY TYPE:
735
ADDRESS:1737 YORK ST.TELEPHONE:
(707) 712-8038
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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03/11/2025 at approximately 9:40 AM , Licensing Program Analysis (LPA) Stevenson conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by DSP-Caregiver Marcel Love who called Administrator Dante Ward who arrived at approximately 10:15AM. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 4 clients in care. Upon arrival, 4 clients were in the facility with one client awaiting transport to day programming.

At approximately 10:40 AM , LPA and administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner.

All rooms were equipped with lighting, night stand, and chest of drawers. The toilet near bedroom #1 was observed to have a cracked and leaking toilet with the wrong size toilet seat and cover (pictures taken)(technical violation issued)

Extra hygiene products and linens were available. Water temperature in sinks accessible to clients in care were measured to be at 117 degrees and within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 02/2025 and found to be fully charged. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to clients to be secured. P & I monies were documented and found to not be co-mingled. Facility conducts quarterly fire and disaster drills.

LPAs conducted a review of 4 client records. Record review, observation and interview with administrator determined that one (1) of four (4) client records did not contain physicians assessment LIC602 and TB clearance, which poses/posed a potential health, safety or personal rights risk to persons in care. (type B deficiency cited)

LPA conducted review of 5 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

Continue on LIC809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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Document Has Been Signed on 03/11/2025 02:08 PM - It Cannot Be Edited


Created By: Star Stevenson On 03/11/2025 at 01:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HIGH POINTE RESIDENCES
FACILITY NUMBER: 486803953

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, recorded review and interview, the licensee did not comply with the section cited above in 1 out of 4 client records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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Licensee to submit physician's assessment LIC602 including TB clearance for C3 by 04/11/2025
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Star Stevenson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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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: HIGH POINTE RESIDENCES
FACILITY NUMBER: 486803953
VISIT DATE: 03/11/2025
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Continued for LIC809

Deficiencies are cited from the California Code of Regulations (CCRs) and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, or repeat violations within a 12 month period, may result in a civil penalty assessment.

LIC500- Personnel Report
LIC308- Designation of Responsibility
Proof of control of property (deed or tax statement)
Updated Emergency Plan LIC610D

Exit interview conducted with Administrator, whose signature on form confirms receipt. Appeal rights provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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