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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600417
Report Date: 08/28/2025
Date Signed: 08/28/2025 04:34:32 PM

Document Has Been Signed on 08/28/2025 04:34 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
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: 3DATE:
08/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:37 AM
MET WITH:Juanito PaguinoTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Sakinah Madyun conducted an unannounced Required Annual Visit on 08/28/2025. LPA was met by Staff #1 James Villanueva and Staff #2 Eduardo Librea and explained the purpose of the visit. S1 and S2 both assisted in the tour of the facility. Administrator Juanito Paguio arrived shortly after the facility tour. The facility is licensed to serve Developmentally Disabled Adults ages 18 to 59 years old and has a fire clearance approved for four (4) ambulatory and (1) one non-ambulatory clients. All clients receive services from Harbor Regional Center. LPA Madyun requested copies of Personnel Report (LIC 500), and Resident Roster (LIC 9020) copies were provided via LPAs cellphone camera.

Physical Plant/Environment Safety: A tour of the single-story facility began at approximately 8:45am that included residents’ rooms: one (1) private staff bedroom, four (4) semi-private bedrooms, two (2) bathrooms, living room, dining area, kitchen, backyard, garage/laundry room/storage space and indoor activity area. All residents’ bedrooms have the required furniture for privacy, comfort, and safety. LPA observed the carbon monoxide detector and inter-connected smoke detectors. Fire extinguisher located in corner of kitchen was fully charged and last inspected 7/24/25. First-aid kit was fully stocked and centrally stored locked in hallway cabinet. LPA observed the Infection Control Plan revised 8/25/25 and Emergency Disaster Plan revised 1/15/25.

Front Yard: Was clean and well maintained without any hazards.

Continued LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/28/2025
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Kitchen: LPA observed enough perishables for two (2) days, and a seven (7) day supply of non-perishables. LPA observed no knives or sharps located in the kitchen cabinets to be inaccessible to four (4) out of four (4) residents in care. LPA Madyun observed several bottles of cleaning solutions and disinfectants located in the bottom kitchen cabinet to be locked away secure and inaccessible to four (4) out of four (4) residents in care. Kitchen appliances were observed to be clean and in working order. LPA observed a fully charged fire extinguisher in the corner of the kitchen area last inspected 7/24/25.

Dining Room/Living room: Dining room was observed to be clean and contained one table with ample seating. The living room was observed with ample seating and lighting.

Linen Closet: Contained sufficient linens, towels, and hygiene products.

Bathrooms: Bathrooms are clean and operational with grab bars, and non-skid mats were hanging, but not in place. Water temperature in resident bathroom #1 was measured at 112.1 degrees Fahrenheit, and bathroom #2 was measured at 114.1 degrees Fahrenheit, which is within the required 105-120 degrees Fahrenheit requirement. Both bathrooms were observed to be clean and in good condition.

Centrally Stored Medications: LPA will return on a later date and time to review client medication logs.

Backyard: LPA observed a shaded seating area with ample seating. No large bodies of water were observed.

Emergency Drills: LPA observed Fire and Safety Drill Report Log recorded drills are conducted monthly with the last drill conducted 8/1/2025.

Staff Personnel Files: LPA interviewed (3) staff files and will return for continuation visit a later date and time to finish staff interviews and review files.

Resident Files: LPA interviewed (4) clients and reviewed (4) client files and will return for continuation visit a later date and time to review medication logs.

Infection Control Plan: The administrator informed LPA Infection Control Plan also sent via mail to the Department on 08/26/2025.

Due to time constraint LPA will return a later date and time for a continuation visit. Exit interview was conducted with Licensee/Administrator Juanito Paguino and a copy of this report and appeal rights will be provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Sakinah Madyun
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
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