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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800324
Report Date: 11/05/2024
Date Signed: 11/05/2024 12:54:48 PM

Document Has Been Signed on 11/05/2024 12:54 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 IIFACILITY NUMBER:
197800324
ADMINISTRATOR/
DIRECTOR:		LOPEZ, CARLOS A.FACILITY TYPE:
735
ADDRESS:940 BRIGHTWOOD ST.TELEPHONE:
(323) 264-3188
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 6CENSUS: 4DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Myro Abunda - Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Myro Abunda and explained the reason of the visit.

The facility is licensed to served 4 ambulatory and 2 non-ambulatory developmentally disabled clients ages 18-59 years old. The facility is located in a residential area and consist of a single home with a living room, a dining room, a kitchen, a laundry area, 3 client bedrooms, 2 bathrooms, 1 staff room a front yard, and backyard.

LPA conducted a tour of the facility with Myro Abunda and observed the following:
Facility is in clean and in good repair indoor and outdoor. Living room and dining are furnished. Kitchen was observed clean. Sharps, medication, and cleaning supplies were observed locked. Food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Laundry area was observed in good repair. Three client bedrooms were observed in good repair, with the required furniture, bedding supplies, and sufficient lighting. Two bathrooms were observed clean and in good repair, water temperature was tested between 117.5-118.7 degrees F., which is within the required 105-120 degrees F. Backyard was observed to provide a covered seating area. All passageways were clear of obstruction and debris. No large bodies of water were observed. A fire extinguisher was observed mounted in the kitchen wall. Carbon Monoxide/Smog detectors were observed, tested, and in working condition.

LPA reviewed files, medication, and P&I for 4 clients. P&I ledger was not updated and money did not match the ledger for 3 clients. Staff files were reviewed for 5 staff. Staff #4(S4) did not have a copy of health screening.

Administrator certificate was observed for Memer Dellosa #6021049735 exp. date: 10/18/24. Renewal documents were submitted to the department in 7/29/24 and are pending. LPA requested documents for change of administrator be submitted within 10 days of this visit. (CONT. LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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 11/05/2024 12:54 PM - It Cannot Be Edited


Created By: Mary G Flores On 11/05/2024 at 11:49 AM
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: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in a copy of infection control plan was not available for review during this visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Administrator will submit a copy of infection control plan to the department by POC due date 11/12/24.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in staff #4 did not have a copy of health screening on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Administrator will obtain a copy of health screening for S4 and submit a copy to the department by POC due date 11/12/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2024 12:54 PM - It Cannot Be Edited


Created By: Mary G Flores On 11/05/2024 at 12:28 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: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (e) Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 3 clients who received P&I funds, ledger was not updated to match the current balances which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Administrator will review ledgers and add/deduct money and ensure that balance matches the amount in each client's ledgers, will submit a copy of the ledger and picture of money to the department by POC due date 11/12/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


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: 11/05/2024
NARRATIVE
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Emergency Disaster plan(version 10/03) and facility's plan were review which does not meet the requirements of version (12/21). Infection control plan was not available for review.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Memer Dellosa and a copy of this report, LIC 809D, and appeal rights ere provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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