197800324-10-26-2023-28-AS-ALOZ-CWYVTC-20231026164256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197800324
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:43:18 PM

Document Has Been Signed on 10/26/2023 04:43 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MIDOMAR HOMES II		FACILITY NUMBER:	197800324
ADMINISTRATOR:	LOPEZ, CARLOS A.		FACILITY TYPE:	735
ADDRESS:	940 BRIGHTWOOD ST.		TELEPHONE:	(323) 264-3188
CITY:	MONTEREY PARK	STATE: CA	ZIP CODE:	91754
CAPACITY: 6		CENSUS: 4	DATE:	10/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:43 PM
MET WITH:	Memer De Lloza		TIME COMPLETED:	04:54 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alberto Lopez made an unannounced annual inspection visit. LPA met with staff Karl Matis, Adoracion Palisoc, Licensee, and Administrator and Memer De Llosa who assisted with the visit. LPA explained the purpose of today's visit. 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. The facility is licensed for 4 ambulatory and 2 non ambulatory. Currently there is 4 clients at facility LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. An Infection Control Plan was not at the facility. Physical Plant & Environment Safety: The facility is free of debris/hazards. There are no security bars or weapons on the premises. The hot water temperature was tested, and temperature measured between 116.2 -118.9 degrees F which is within required range of 105.0 -120.0 F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are inaccessible to clients. Cabinet with cleaning solutions was locked by staff during visit. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and recently inspected.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 II	FACILITY NUMBER: 197800324
	VISIT DATE: 10/26/2023

NARRATIVE

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Operational Requirements: Facility is complying with operational requirements.

Staffing: There appears to be sufficient staffing in the facility. CPR/First aid certificates are on file. Administrator Assistant Administrator Certificate expires on 10/24/2024. Last fire drill was on 03/09/23.

Personnel Records-Training: Staff has criminal record clearance. Staff files are not maintained at the facility. Staff have current CPR/first aid training and documentation of ongoing training.

Client Rights-Information: Client personal rights poster is posted in the facility. Internet access is available for clients. No postural supports are used at facility.

Client Records-Incident Reports: Client files are not kept within the facility but were brought over by administrator and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Services: Staff designated to administer medication do have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked medication cabinet located in the kitchen. All medications are properly labeled and in their original containers. During the visit today, LPA reviewed all 4 clients' medications, all medication is administered according to doctor’s orders.
Incidental Medical Services: Facility is complying, no client with restricted health condition at facility.
Disaster Preparedness: The facility has an Emergency Disaster Plan at facility but needs updating.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

Deficiencies cited during today's visit. Technical advisories were also provided.

An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/26/2023 04:43 PM - It Cannot Be Edited

Created By: Alberto Lopez On 10/26/2023 at 04:26 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: MIDOMAR HOMES II	FACILITY NUMBER: 197800324
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

85065.6(b)(1)

Night Supervision

(b) Employees providing night supervision from 10:00 p.m. to 7:00 a.m., as specified in (c) through (f) below, shall be available to assist in the care and supervision of clients in the event of an emergency, and shall have received training in the following: (1) The facility's planned emergency procedures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation interview, record review, the licensee did not comply with the section cited above. Staff stated they do not have training in emergency procedures which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/27/2023
	Plan of Correction
1 2 3 4	Administrator will train staff on emergency procedures and the facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: The location of utility shutoff valves and instructions for use and send proof to LPA by POC date.

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.

SUPERVISOR'S NAME:

Lisa Hicks

LICENSING EVALUATOR NAME:

Alberto Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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