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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803953
Report Date: 07/11/2023
Date Signed: 07/11/2023 05:34:08 PM

Document Has Been Signed on 07/11/2023 05:34 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: 3DATE:
07/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Dante Ward, Licensee/AdministratorTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Case Management - Deficiencies inspection. LPA met with Licensee/Administrator Dante Ward.
LPA arrived to deliver findings on complaint investigation (control# 21-AS-20230407164133) and address deficiencies previously observed at High Pointe Residences.

During record review for a case management - annual continuation inspection dated 03/21/2023, LPA reviewed client's facility files and observed 3 of 4 clients (C1, C2 , C3) did not have an LIC 602 Physician's Report completed or in file. LPA requested client's to be evaluated by their primary physician and to complete the LIC 602 as required and LPA provided a technical violation advisory note on 03/21/2023. Administrator stated they would complete and send to LPA.
LPA opened complaint (control# 21-AS-20230407164133) on 04/11/2023 and observed C1, C2 , C3 still did not have their LIC602 completed as required. LPA requested Administrator have C1, C2, C3 evaluated by their medical physician and submit copies of their LIC602s. LPA received C1's LIC 602 on 04/20/2023 and and copy of LIC602 for C2 on 04/20/2023. However, C2's LIC602 was missing attached forms including C2's Tuberculosis (TB) test results. LPA requested copies of C2's attached forms on 04/20/2023 to verify C2's TB test results, however Administrator did not reply or submit C2's attached medical records that LPA requested.
As of today 07/11/2023, LPA did not receive C3's LIC602 or C2's TB test results. Licensee did not comply with regulation despite several warnings previously provided.

Deficiencies from California Code of Regulations and Health & Safety Code, (Title 22, Division 6 & Chapter 8), is being cited on the attached LIC 809D. Appeal rights provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/11/2023 05:34 PM - It Cannot Be Edited


Created By: Karina Canela On 07/11/2023 at 04:00 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: 07/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
80069(b)

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80069 Client Medical Assessment - (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 was not met as evidenced by:
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Licensee to submit complete LIC602's for clients C2 & C3 to community care licensing. Licensee to submit a written statement that they understand the regulaiton and will be in future compliance. POC due by 07/14/2023
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Based on record review and interviews, licensee did not comply with the regulation above in 3 of 4 clients, due to accepting clients without obtaining a medical assessment per reg. This is a potential health, safety, and personal rights risk to clients in care.
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Type B
07/14/2023
Section Cited
CCR80069(c)(1)

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80069 Client Medical Assessment - (c)The medical assessment shall include the following: (1)The results of an examination for communicable tuberculosis and other contagious/infectious diseases.
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Licensee to submit C2's TB test results to community care licensing for review. Licensee to submit a written statement that they understand the regulaiton and will be in future compliance. POC due by 07/14/2023
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Based on record review and interviews, licensee did not comply with the regulation above in 1 of 4 clients, due to not having Client (C2)'s TB test results on file and not providing a copy to CCL when requested for verification. -------------->
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------> This is a potential health, safety, and personal rights risk to clients in care.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
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