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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800324
Report Date: 10/21/2025
Date Signed: 10/21/2025 03:08:27 PM

Document Has Been Signed on 10/21/2025 03:08 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:
10/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:23 PM
MET WITH:Memer Dellosa TIME VISIT/
INSPECTION COMPLETED:
03:17 PM
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced annual inspection visit. LPA met with staff Josefina Lopez and Administrator and Memer Dellosa 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 are 4 clients at facility

LPA 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 116.4 -118.7 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. Smoke detectors and carbon monoxide detectors are operable and in compliance. However, one smoke detector had weak battery and sound was too low. Administrator changed the battery during visit. The fire extinguishers were observed and recently inspected.

(Continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 10/21/2025
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(continued from 809)
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 Certificate expires on 10/18/2026. Last fire drill was on 09/02/2025.

Personnel Records-Training: Staff has criminal record clearance. Staff files are 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.

Food Service: The kitchen was observed for its 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.

Client Records-Incident Reports: Client files are kept within the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.

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 of de-escalation techniques.

No deficiencies cited during today's visit. Technical advisories were provided.

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

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC809 (FAS) - (06/04)
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