198600417-7-16-2026-28-AS-EMAT-DW2VVX-20260716164704

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600417
Report Date: 07/16/2026
Date Signed: 07/16/2026 04:47:19 PM

Document Has Been Signed on 07/16/2026 04:47 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 HOME		FACILITY NUMBER:	198600417
ADMINISTRATOR/ DIRECTOR:	MARILYN M. PAGUIO		FACILITY TYPE:	735
ADDRESS:	12013 HIGHDALE STREET		TELEPHONE:	(562) 929-8371
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 4		CENSUS: 4	DATE:	07/16/2026
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Administrator Juanito Paguio		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

NARRATIVE

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Licensing Program Analyst (LPA ) Elena Mallett arrived at the facility to conduct an unannounced Annual Continuation visit. The first visit was conducted on 07/13/26. LPA returned today to complete the remaining domains in the CARE tool. LPA met with Administrator Juanito Paguio and the purpose of the visit was explained. The facility is licensed to serve developmentally disabled adults ages 18-59 years old, one which may be non-ambulatory.

LPA toured the common areas of the facility and no immediate health and safety risk were observed.

LPA completed the visit using Compliance and Regulatory Enforcement Tools (CARE) . The following domains were completed during the visit.

Personal Records - Training: Locked storage space for staff files was observed. 5 staff files were reviewed for Criminal Background Clearance, First Aid training, initial and ongoing training and health screening. No issues were observed. Administrator Paguio Administrator's certificate is current until 01/13/2028.

Health Related Services: First Aid Kit and manual was observed. Facility utilizes a Medical Record Log. All four clients' medicine logs were reviewed with no issues. The medication is kept locked and centrally stored. Staff was properly trained to dispense medication. One client has a restricted health condition and documentation related to care and staff training was observed.

Client Records - Incident Reports: Locked Storage space for client files was observed. 5 client files were reviewed for Emergency Face sheet, Physician’s Report with ambulatory status, Needs and Services plan, Admission Agreement and Personal Rights. A deficiency was cited. See 809-D. Facility dispenses P&I money to clients. All four clients' files were reviewed with no issues. Facility maintains a current Surety Bond.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

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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Document Has Been Signed on 07/16/2026 04:47 PM - It Cannot Be Edited

Created By: Elena Mallett On 07/16/2026 at 04:21 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: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(c)(4)

Client Medical Assessments

(c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 4 client files did not contain a Physician's Report (C2) with ambulatory status designated which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2026
	Plan of Correction
1 2 3 4	By POC date Administrator will fax to LPA a Physcian's Report for C2 with ambulatory status designated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:

	Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

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: 07/16/2026

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Client Rights - Information: Client with disabilities personal rights and CCLD poster were not observed. Administrator posted signs during visit. Clients are provided with telephone and internet access.

Operational Requirementsz: Facility maintains a Fire clearance. Activities are available to clients such as attending concerts in the park, trips to the mall and library, walks in the park and card and bingo games.

Staffing: Sufficient staff is available for clients in care and have received training in CPR and First Aid.

Emergency Intervention: Manual restraints are not utilized by facility.

A deficiency was cite today Per Title 22. An exit interview was conducted with Administrator Juanito Paguio and a copy of this Licensing Report was provided along with Appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC809 (FAS) - (06/04)

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