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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600417
Report Date: 07/16/2024
Date Signed: 07/16/2024 01:30:53 PM

Document Has Been Signed on 07/16/2024 01:30 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HIGHDALE HOMEFACILITY NUMBER:
198600417
ADMINISTRATOR/
DIRECTOR:		MARILYN M. PAGUIOFACILITY TYPE:
735
ADDRESS:12013 HIGHDALE STREETTELEPHONE:
(562) 929-8371
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 4CENSUS: 4DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Wilma Hintay, StaffTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Daniel Konishi and Christine Wong conducted an unannounced Annual Required Visit on 07/16/2024. LPAs were met by Staff #1 (S1) and explained the purpose of the visit. S1 assisted in tour of facility. Administrator Juanito Paguio arrived shortly after to the facility. The facility has a fire clearance approved for four (4) ambulatory and (1) one non-ambulatory clients. All clients receive services from Harbor Regional Center. LPAs requested and obtained a copy of Personnel Report, and Resident Roster.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has no infection control plan in place.



Physical Plant/Environment Safety:
· LPA conducted a tour of the facility with S1, DSPs and observed the following: The facility is a single-story building in a residential area, with a kitchen, dining room, living room, family room, 4 client bedrooms, 1 live in staff bedroom, 2 bathrooms, backyard with shaded area and a detached garage.
· All passageways, walkways, driveway, steps and patio are free from obstructions. The front, back and side areas of the house are free of hazards.
· Hallway linen closet: Contained plenty of linens, towels, and hygiene products.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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 9
Document Has Been Signed on 07/16/2024 01:30 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/16/2024 at 12:14 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHDALE HOME
FACILITY NUMBER: 198600417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed that the facility does not have a Infection Control Plan in place which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Administrator will send current Infection Control Plan to LPA by POC due date.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed ants crawling on the wall in the living room which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Administrator will write up a plan on how to keep the facility free from ants and other insects and send the plan to the LPA by the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2024 01:30 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/16/2024 at 12:14 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHDALE HOME
FACILITY NUMBER: 198600417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Administrator's file is missing training on HIV and TB which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Administrator will send a copy of the HIV and TB training certificate to the LPA by the POC due date.
Type B
Section Cited
HSC
1507(c)(1)(D)
General Provisions
(D) Facility staff shall be trained by the identified health care professional practicing within his or her scope of practice who shall monitor, according to the individualized health care plan, the staff's ability to provide incidental medical services and who shall review, correct, or update facility staff training as the health care professional deems necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA did not observe updated health care training for C1's restricted health condition which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Administrator will send the staff training logs for C1's restricted health condition to the LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/16/2024 01:30 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/16/2024 at 12:14 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHDALE HOME
FACILITY NUMBER: 198600417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092.1(k)(2)
General Requirements for Restricted Health Conditions
(k) If the licensed health professional delegates routine care, the following requirements must be met for health conditions specified in Sections 80092.3, 80092.4 and 80092.6 through 80092.11: (2) The licensee ensures that the licensed professional reviews staff performance as often as necessary, but at least annually.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the LPA observed the facility does not have C1's updated restricted health care plan in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Administrator will send C1's updated restricted health care plan to the LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HIGHDALE HOME
FACILITY NUMBER: 198600417
VISIT DATE: 07/16/2024
NARRATIVE
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· Beds have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition.
· Fire extinguisher was observed on hallway last reviewed 07/11/2024.
· Smoke/carbon monoxide detectors are tested and in working condition.
· Cleaning supplies are kept locked under kitchen sink away from food supplies.
· Sharps are kept locked in a drawer in the live in staff bedroom.
· Shared client bathrooms were observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom#1 was measured at 105.6 degrees F and Bathroom #2 was measured at 109.5 degrees F which is in the required 105 – 120 degrees F per Title 22 Regulations.

Operational Requirements:
· The facility is licensed to serve (4) four ambulatory developmentally disabled adults ages 18 thru 59 years old and (1) one non-ambulatory.

Staffing:
· A total of five (5) full-time staff members provide care and supervision to the clients.

Personnel Records / Staff Training:

· Administrator’s certificate effective to 01/13/2026.


· Administrator does have required HIV & TB training.
· Three (3) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.
· Facility does not have sufficient staff training.

Client Rights/Information:
· Physician orders were reviewed in client files.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HIGHDALE HOME
FACILITY NUMBER: 198600417
VISIT DATE: 07/16/2024
NARRATIVE
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Client Records/Incident Reports:
· Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, TB clearance, Individual Program Plan, Appraisal/Needs and Services Plan, personal rights,medication records, and Personal and Incidental (P & I) money were reviewed.

Food Services:


· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
· No restricted Health Care plan required for the clients in the facility.

Health Related Services:
· Clients are assisted with self-administration of prescription and non-prescription medications.

· Four (4) centrally stored resident medication records were reviewed.


· First Aid Kit was reviewed and has required items.
· LPA observed cabinet located in hallway to be locked and inaccessible to residents. LPA reviewed four (4)
out of four (4) client medications and Medication Administration Record (MAR).

Incidental Medical and Dental:
· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· The facility has one client, C1 under restricted health conditions and does not have an updated restricted health care plan.

· The facility does not have staff training for restricted health conditions.

Disaster Preparedness, and Emergency Intervention:


· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· An emergency drill was last documented on 07/01/2024.


SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HIGHDALE HOME
FACILITY NUMBER: 198600417
VISIT DATE: 07/16/2024
NARRATIVE
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Emergency Intervention:
· No manual restraints or seclusion are used with clients in care.

Deficiencies were noted on LIC809-D per Title 22 Regulations. Interview was conducted and copy of the report and Appeal Rights were provided to the S1.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 07/16/2024 01:30 PM - It Cannot Be Edited


Created By: Daniel Konishi On 07/16/2024 at 12:46 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HIGHDALE HOME
FACILITY NUMBER: 198600417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(b)(6)
80022 Plan of Operation

(b) The plan and related materials shall contain the following:
(6) Plan for inservice education of staff if required by regulations governing the specific facility category.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed facility has no staff training documented in file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Administrator will send staff training logs to the LPA by the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


LIC809 (FAS) - (06/04)
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