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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600417
Report Date: 07/24/2023
Date Signed: 07/25/2023 08:10:34 AM

Document Has Been Signed on 07/25/2023 08:10 AM - 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HIGHDALE HOMEFACILITY NUMBER:
198600417
ADMINISTRATOR:MARILYN M. PAGUIOFACILITY TYPE:
735
ADDRESS:12013 HIGHDALE STREETTELEPHONE:
(562) 929-8371
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 3DATE:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Wilma Hintay TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Staff, Wilma Hintay and explained the reason for the visit. Administrator Marilyn Paguio arrived at the facility a short time later and assisted with the visit.

The facility is licensed to serve 4 clients between the age of 18 and 59 years old and 1 non- ambulatory. The facility is vendored through Harbor Regional Center. The facility is a single-story building in a residential area, with a kitchen, dining room, 2 living room, 4 client bedrooms, 1 staff bedroom, 2 bathrooms, backyard with shaded area and a detached garage. Fire extinguisher observed kitchen fully charged. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational.

LPA, toured the facility inside and out, reviewed food supply, reviewed staff and client files, and reviewed resident medications. Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. The front and backyard are well maintained. The resident bathrooms are clean, and showers have non-skid materials. The hot water temperature measured at 111.3 degrees F. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE in the garage. Infection control signs were observed throughout the facility. Medications reviewed for all clients and appears to be given as prescribed. Last emergency disaster drill was conducted on 7/01/23.
No deficiencies cited during today's visit. Exit interview conducted, copy of report provided to Ms. Paguio.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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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