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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800324
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:42:37 AM

Document Has Been Signed on 11/04/2022 11:42 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Emilio Rances, StaffTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPAs) Cynthia Chan and Kimberly Ramirez conducted the unannounced annual inspection with the focus of the infection control domain. LPAs were allowed entry by Staff, Emilio Rances, and the purpose of the visit was explained. Administrator, Memer Dellosa, arrived shortly to provide assistance. The facility is licensed for 6 developmentally disabled adults, ages 18 to 59, and of which 2 may be non-ambulatory. There are currently 3 clients residing in the home and receive services from the Eastern Los Angeles Regional Center.

LPAs toured the facility and observed the following:
* There are 4 bedrooms (3 for clients and 1 for live-in staff), 2 bathrooms, living room, dining room, kitchen, laundry area, and an attached garage. The backyard consists of a shaded area with a table and chairs for client use.
* Covid-19 signage are posted throughout the home. Hand washing signs are posted in the bathrooms.
* PPE station is set up by the front door. Extra PPE supplies of at least 30 days are observed in the home.
* The facility has a Covid-19 screening log and documents temperature of staff and clients.
* Food supplies of 2 day perishable and a week of non-perishable are observed.
* The smoke detectors and a carbon monoxide detector were tested and operable.
* Medications are centrally stored and locked in the kitchen cabinet. LPAs reviewed all 3 clients medications and the medications are being administered as prescribed.
* 3 Staff files were selected to ensure they have current first aid/CPR training and a health screening form. Interviews were conducted with the Administrator and 2 Staff.
* All 3 client files were reviewed and have updated emergency contact information.
* Staff were wearing a face mask.
LPA provided a technical advisory for continuous screening of all visitors.
No deficiency was issued during the visit today. An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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