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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600417
Report Date: 08/27/2021
Date Signed: 08/27/2021 02:32:58 PM

Document Has Been Signed on 08/27/2021 02:32 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
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:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marilyn Paguio, administratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was greeted by caregivers in charge and was later assisted by administrator Marilyn Paguio and discussed the purpose of today's visit. This single-story home contains five (5) bedrooms, two (2) bathrooms, two (2) living rooms, a kitchen, dining room, backyard, and detached garage.
The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, hand sanitizer, masks, and sign-in sheet. A temperature check log for staff and clients was maintained daily.
  • COVID-19 signage was placed in several areas including entrance, hallways, and bathrooms.
  • Facility did not maintain a 30-day supply of PPE.
  • There was a sufficient supply of 2-day perishables but insufficient 7-day supply of non-perishable foods. There was insufficient supply of canned fruit and canned meat.
  • Cleaning solutions and sharps were locked and inaccessible.
  • Water temperature was measured in kitchen/bathrooms and were not within required 105-120 degrees F. (Kitchen: 103.8 degrees, bathroom 1: 98.6 degrees, bathroom 2: 104.6 degrees).
  • All client rooms contained required furniture including bed, dresser, night stand, lamp and chair.
  • Medications were locked, centrally stored and given as prescribed. However, facility did not maintain 30-day supply of medications.
  • Staff wore face masks throughout their shift and furniture was placed to encourage physical distancing.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • Indoor and outdoor passageways were free from obstruction.
  • At least one (1) fire extinguisher was observed to be fully charged and last serviced on July 2021.
  • Three (3) areas of disrepair were observed: two (2) out of (4) stove burners did not ignite; large areas of peeling wood was observed on client bedroom door; dislocated screen on one (1) of (2) crawl spaces.
  • Client files were inspected and emergency contact information and physician's reports were up to date.
  • Staff files were inspected and contained required health screenings, criminal record clearances, and trainings. Administrator certificate expires 7/2023.
Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted and a copy of this report and appeal rights were provided to the administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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Document Has Been Signed on 08/27/2021 02:32 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 08/27/2021 at 01:59 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: 08/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 faucets which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2021
Plan of Correction
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The water meter was adjusted immediately and water temperature measured within 105-120 degrees. In addition, the administrator stated that the staff will measure the water temperature twice a day for the next 7 days and document on a log. Administrator will send log to CCL by 9/3/21.
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for non-perishables foods due to lack of canned fruits and low supply of canned meats, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2021
Plan of Correction
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The administrator stated that she will purchase or obtain more canned fruits and canned meats and provide copy of receipt to CCL within 24 hours.
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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2021


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/27/2021 02:32 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 08/27/2021 at 02:00 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: 08/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the following items: 2 out of 4 stove burners did not ignite; client bedroom door wood was peeling off; 1 out of 2 screens on crawl space was in disrepairs. This posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2021
Plan of Correction
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The administrator stated that she will order and repair the items and provide picture proof and/or receipts of repaired items 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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2021


LIC809 (FAS) - (06/04)
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