Highgate Senior Living-temecula.

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Lyssa Irani, community resources manager, and informed them of the purpose of the visit. At the time of the visit, there were 35 staff members and 91 residents present. Facility Overview: The facility is a two story building with (88) bedrooms and (95) bathrooms. There are no swimming pool or known firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility has infection control plan in file. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. The facility has laundry facility operated by staff for the residents in care. Sharp and dangerous objects were securely locked and inaccessible to residents. LPA reviewed state fire marshal inspection report dated 03-25-2025 and observed that the facility passed the fire safety inspection. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. LIC809-C.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five (5) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for five (5) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 12-20-2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.

For allegation, food service inadequate. During staff interviews, 6 out of the 6 staff stated the facility has adequate food available for residents. In addition, 6 out of the 6 staff informed LPA that the facility has a variety of food options for residents to select. During resident interviews, 7 out of the 7 residents stated the food service is adequate and is provided in a timely manner. During facility tour and record review, LPA Rico observed the facility had variety of food available for residents. In addition, the facility also has a food menu posted along with options for residents to select. For the allegation, the resident contract is not adhered to. During staff interviews, 3 out of the 6 staff stated residents’ contract is adhered to, no changes are made without resident and their responsible party consent. Based on the evidence found during the investigation, the three (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Assisted Living Coordinator (ALC), Melissa Villafana .

On 1/22/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Community Resources Manager (CRM), Lyssa Irani who was informed of the purpose of the visit. The facility is licensed to serve 99 non-ambulatory residents of which 10 may be bedridden. The facility also has an approved hospice waiver for 30 residents and LPA was informed 18 residents are currently receiving hospice services at the facility with one (1) deemed bedridden. LPA toured the facility with CRM. The facility is made up of a two-story building designated for assisted living and memory care. The memory care unit wings of the building are approved for delayed egress. CRM tested the delayed egress and LPA observed it to operational. Outside shaded seating is available for resident use. Indoor and outdoor passageways are free of obstruction. There are no bodies of water on the premises. LPA toured the kitchen and observed the facility has more than a two-day supply of perishable food and seven-day supply of non-perishable food items, which are stored in a safe and healthful manner. LPA also observed a cork board in the kitchen noting residents’ food allergies and dietary needs. The facility offers several activities and outings for resident leisure. Medications are secured in medication carts, only accessible to authorized personnel such as medication technicians. Resident files reviewed had updated physician's reports and signed admission agreements. LPA observed fire alarm systems, carbon monoxide detectors, and charged fire extinguishers throughout the facility. CRM contacted the facility's fire alarm company who reported the facility's fire alarms can only be tested by using a designed aerosol can containing a fine mist simulating smoke and spraying it directly towards one (1) of the smoke detectors to trigger the fire alarm. During the visit, the facility did not have the aerosol can available; therefore, facility staff was unable to physically test the fire alarms. As a result, LPA reviewed the facility's System Record of Inspection and Testing (SRIT) dated 3/14/2024, noting the fire alarms were last tested on 3/14/2024, by the facility's fire alarm monitoring company Addax Electric Inc. Per the SRIT, the fire alarms were found to be functioning properly. The facility's last fire drill was conducted on 12/17/2024. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to CRM.

LPA conducted an interview with R1’s POA agent who reported they were informed by R1's family that R1 was observed more confused than usual and required medication. R1's POA agent reported R1 has a private caregiver who reported to them that R1's level of confusion was at their baseline. R1's POA agent reported they never instructed facility staff to not administer the medication and were simply waiting on additional information from medical professionals before agreeing to the medication in question due to receiving conflicting information from R1’s family and private caregiver. Assistant Healthcare Director (AHD), Veronica Chavez was interviewed, corroborated the information provided by R1’s POA agent, and reported the facility did not have a signed doctor’s order to administer the medication on 8/6/2024. AHD reported they assessed R1 on 8/6/2024 and 8/7/2024 and R1 was not observed with any symptoms of acute distress. AHD reported the facility received the signed doctor’s order for the medication in question on 8/8/2024 and immediately began administering the medication as prescribed. LPA reviewed R1’s hospice care plan dated 2/2/2024 and conducted an interview with R1’s case manager who corroborated the facility did not receive a signed doctor’s order to administer the medication until 8/8/2024. LPA reviewed hospice’s “Written Confirmation of Telephone Orders” dated 8/7/24 for the medication in question, which noted the physician’s signature was obtained on 8/8/2024. LPA reviewed the Physician’s Order as of 8/16/2024 where the facility documented receiving the medication on 8/8/2024. LPA reviewed R1’s medication administration record for August 2024 and the facility documented administering the medication in question from 8/8/2024 to 8/16/2024. LPA also made contact with the reporting party who reported they do not have any concerns with the care or supervision R1 receives at the facility including medication management. This agency has investigated the complaint alleging “Staff are not administering medication(s) to resident according to physicians instructions”. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to Administrator Gomez.

Five (5) staff were interviewed and all reported being able to use a master key to unlock R1's bedroom door from the outside. Five (5) staff interviewed reported not having knowledge of any resident doorknobs in disrepair. Additionally, LPA reviewed the facility's Maintenance Requests for September 2024 and did not observe a request to repair/replace R1's bedroom door knob. Based on the aforementioned, this agency has investigated the complaint alleging "Staff does not ensure bedroom door for resident is in good repair". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Gomez and HD Larson.

On 1/16/2024, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA met with Community Resource Manager, Lyssa Irani who was informed of the purpose of visit. LPA toured the Assisted Living and Memory Care Unit with Lyssa Irani. The following was observed, reviewed, and inspected: The physical plant, in general, was in good repair. The facility is operating in the capacity approved by Community Care Licensing (CCL). The buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. LPA inspected a sample of resident bedrooms and bathrooms in the Assisted Living & Memory Care Unit. Resident bedrooms have the required bedding and furniture; such as clean mattresses, night stands, storage space, and sufficient lighting. Room temperatures were comfortable for residents in care. LPA inspected a sample of resident bathrooms; the bathrooms were equipped and operating in safe and sanitary conditions. LPA measured the hot water temperature in the sampled bathrooms, in which all bathroom sinks measured within regulation. Sampled bathrooms were equipped with non-skid surfaces and grab bars. Bedrooms were equipped with a pull cord system to notify staff of any emergencies. LPA toured the kitchen and dining area. The facility was stocked with a 2-day supply of perishable and 7-day supply of non-perishable food items that were labeled appropriately. The facility had a menu posted and available for review. Dishes, glasses, and utensils were in good condition and stored in a healthful manner. LPA inspected the common areas. LPA observed several carbon monoxide and smoke detectors alarms throughout the facility. Carbon monoxide & smoke detector were tested and functioning properly. There was a locked and centralized storage area for medications, including refrigerated medications. Medications appeared to be dispensed and documented appropriately. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The facility had a designated area for resident files and staff files. All staff present have a criminal record clearance in file and are confirmed as being associated with the facility. Random staff and residents' records were reviewed. All required postings were posted in prominent areas and throughout the facility. There was adequate seating in the common areas and several activity rooms. LPA observed several activity posters. The facility was also equipped with a complete first aid supplies as well as the first aid manual. LPA inspected the outdoor area of the facility. There was shaded area with seating. Overall, the facility was clean, in good repair, and operating in safe conditions for residents in care. During LPA’s visit, LPA observed facility has no Administrator. Lyssa informed LPA that facility has had no administrator since 1/2/2024. However, the facility has interviewed few prospective candidates and is in the process of hiring a new Administrator this week. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed, and a copy was provided to Lyssa Irani.

On 10/3/2023, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to conduct a health and safety visit at the facility to follow up on a fire that took place at the facility on 10/2/2023. LPA met with Community Resources Manager, Lyssa Irani and Maintenance Manager, Daryl Wilkes who were informed of the purpose of the visit. LPA was informed that on 10/2/2023, at approximately 11:30 p.m., there was a fire that ignited in the kitchen. Facility staff contacted the local fire department for assistance. Southern California Edison (SCE) also arrived at the facility to inspect the affected area. SCE determined the fire was not caused by electricity or an electrical fault. The kitchen area was not occupied by residents or staff when the fire started, and there were no injuries to residents or staff reported. The fire department reported the fire sprinkler system at the facility was immediately activated, and the water from the fire sprinklers extinguished the fire. During the visit, LPA inspected the kitchen area and observed a kitchen wall and ceiling tiles to be burned. LPA was informed the facility discarded some food supply that was saturated from the fire sprinkler water. The facility is in the process of replenishing the food supply that perished. The facility anticipates reopening the kitchen on 10/9/2023. A written meal plan will be submitted to LPA by close of business today. Based on Fire Safety Specialist Lorri Larson's inspection, there are only cosmetic damages to the kitchen wall and ceiling as a result of the fire. The kitchen will remain closed until repairs are made and approval is obtained from Fire Safety Specialist Larson. CRM Irani has notified resident's responsible parties of the incident. During today's visit, LPA did not observe any immediate health and safety concerns. A copy of this report was reviewed and provided to CRM Irani.