197800324-10-3-2024-28-AS-TVAO-D9QV7S-20241004161134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197800324
Report Date: 10/03/2024
Date Signed: 10/03/2024 04:47:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2024 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240911141009

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:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator Memer De la rosa		TIME COMPLETED:	09:15 AM

ALLEGATION(S):

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Facility keeps food locked and not accessible to the clients
Facility does not maintain an adequate temperature
Facility is in disrepair
Facility is not meeting the clients' needs
Facility is administering medication not prescribed by a physician
Facility did not administer medication as prescribed
Facility did not provide night supervision to the clients

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 10/02/2024, to deliver findings regarding the above allegations. LPA Ramirez conducted initial complaint investigation on 09/17/2024 and a needs further investigation was documented. LPA Ramirez was Direct Support Staff Myro Abunda and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 3 interviews (S1 – S3), Attempted interview of Client#1-4 (C1 – C4), copies of Client#1-4 (C1-C4) Admission Agreement, C1- C4 Individual Program Plan (IPP), Consultant Summary Hours from 01/2024 through 08/2024, Eastern Los Angeles Reginal Center Corrective Action Plan (CAP) dated 09/06/2024, Time sheet for staff (S1 – S5) dated 06/19/2024 – 06/22/2024, Physician’s Order for C2 dated 11/01/2023, and physical plant tour.
See 9099-C for continued narrative.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240911141009

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/03/2024

NARRATIVE

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The investigation revealed the following. Regarding Allegation: Facility keeps food locked and not accessible to the clients – It is alleged staff keep food locked up in kitchen cabinets. On 09/17/2024, LPA Ramirez conducted a physical plant tour of the facility. LPA Ramirez observed kitchen cabinets to contain key cabinet locks. LPA Ramirez observed these cabinets to be unlocked and observed nonperishable food in cabinets. Three (3) out of the three (3) staff interviewed denied this allegation. Staff interviews revealed that although, the kitchen cabinets do contain key locks, staff does not lock cabinets that contain food. LPA Ramirez was unable to interview clients due to clients’ being mostly non-verbal. LPA Ramirez observed clients in care to be well groomed and well nourished. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Facility does not maintain an adequate temperature - It is alleged on 08/21/2024, the facility indoor thermostat read 85 degrees F. On 09/17/2024, LPA Ramirez conducted a physical plant tour of the facility. LPA Ramirez observed the facility indoor thermostat to read 74 degrees F. Per Title 22, Division 6, Chapter 1, Article 07. Physical Environment- 80088 Furniture, Fixtures, Equipment and Supplies (a)(1)- (a) A comfortable temperature for clients shall be maintained in all areas. (1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and maximum of 85 degrees F (30 degrees F). Three (3) out of the three (3) staff interviewed denied this allegation. LPA Ramirez was unable to interview clients due to clients’ being mostly non-verbal. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Facility is in disrepair- It is alleged on 08/21/2024, the facility’s air conditioner was in disrepair. On 09/17/2024, LPA Ramirez conducted a physical plant tour of the facility and observed the facility air conditioner to be operational. LPA Ramirez observed a central air conditioning unit located on outside of the facility, near the covered patio area. LPA Ramirez observed the unit to be free from debris and LPA Ramirez observed the fan inside the unit to be operational. Indoor facility thermostat read 74 degrees F at 12:20 pm. Three (3) out of the three (3) staff interviewed denied this allegation. LPA Ramirez was unable to interview clients due to clients’ being mostly non-verbal. Per Administrator Del la Rosa, the facility air conditioning has not been in disrepair or required servicing within the last year. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

See 9099-C for continued narrative.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240911141009

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/03/2024

NARRATIVE

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Facility is not meeting the clients' needs- It is alleged staff does not meet the clients by not providing 16 hours of consulting hours, per client, for each consecutive 6 months. On 09/20/2024, LPA Ramirez requested and obtained consultant summary hours dated 01/2024 through 08/2024 for C1-C4. According to this summary, C1- C4 received more than 16 hours of consulting hours from 01/2024 through 08/2024. Three (3) out of the three (3) staff interviewed denied this allegation. LPA Ramirez was unable to interview clients due to clients’ being mostly non-verbal. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Facility is administering medication not prescribed by a physician- It is alleged facility staff may have administered unprescribed Promethazine (6.25 mg) and Tramcinolone % to C1. On 09/17/2024, LPA Ramirez reviewed C1’s client file and observed a physician’s order for PRN -Promethazine (6.25 mg). C1’s Individual Program Plan (IPP) (dated 02/24/2024) lists PRN -Promethazine (6.25 mg), as medication currently ordered by C1’s physician. LPA Ramirez observed a bottle of Promethazine (6.25 mg) in C1’s tray of prescribed medications. LPA Ramirez did not observe a physician’s order for Tramcionlone % in C1 client file. LPA Ramirez did not observe Tramcinolone % in C1’s medication tray. Three (3) out of the three (3) staff interviewed denied this allegation. LPA Ramirez was unable to interview clients due to clients’ being mostly non-verbal. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Facility did not administer medication as prescribed- It is alleged staff did not administer C2 their prescribed medication of Systane Ultra eye drops, as directed. On 09/17/2024, LPA Ramirez reviewed C2’s client file and observed a physician’s order to discontinue use of Systane Ultra as of 11/01/2023. Three (3) out of the three (3) staff interviewed denied this allegation. LPA Ramirez was unable to interview clients due to clients’ being mostly non-verbal. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Facility did not provide night supervision to the clients- It is alleged that staff did not provide night supervision on 06/19/2024. On 09/20/2024, LPA Ramirez requested and obtained time sheets for all staff, starting 06/16/2024 through 06/22/2024. According to time sheet dated 06/19/2024, S3 began their shift at 2pm till 11pm, S5 began their shift at 2pm till 10pm, and S4 began their shift at 10pm till 6am. Three (3) out of the three (3) staff interviewed denied this allegation. LPA Ramirez was unable to interview clients due to clients’ being mostly non-verbal. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
No deficiency was cited for this complaint investigation. Exit interview was conducted and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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