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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800324
Report Date: 07/28/2022
Date Signed: 07/28/2022 05:05:21 PM

Document Has Been Signed on 07/28/2022 05:05 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:MIDOMAR HOMES IIFACILITY NUMBER:
197800324
ADMINISTRATOR:LOPEZ, CARLOS A.FACILITY TYPE:
735
ADDRESS:940 BRIGHTWOOD ST.TELEPHONE:
(323) 264-3188
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 6CENSUS: 3DATE:
07/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Emilio Rances, caregiverTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit for the death of a client. LPA met with staff, Emilio Rances and explained the reason for the visit. The facility submitted a death report on 7/15/22 regarding death of Client #1.

Per the Administrator and Staff #1, Staff noticed that Client #1 was a little bit weak starting in the afternoon on 7/13/22. Staff took Client's temperature and did not have a fever. Staff did not see any signs of distress or emergency needed. The Client appeared normal except for being a little weak. The next day on 7/14/22, Client did the normal routine in the morning and after lunch, client took a rest. Temperature and vital signs were normal. When Client #1 asked to go to the restroom, staff #1 assisted in changing the diaper. The Client fainted and fell to the bed, unresponsive. Staff immediately performed CPR while another called 911. The paramedics came and took over the CPR. Client #1 was pronounced deceased on 7/14/22 at the facility.
LPA obtained copies of the Face Sheet and Medication log from May through July 2022. The Administrator will email the Physician's Report and Regional Center IPP later today.

LPA requested for a copy of the death certificate when it is obtained.

An exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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