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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800590
Report Date: 05/16/2023
Date Signed: 05/16/2023 04:47:27 PM

Document Has Been Signed on 05/16/2023 04:47 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 IIIFACILITY NUMBER:
197800590
ADMINISTRATOR:CARLOS A. LOPEZFACILITY TYPE:
735
ADDRESS:2032 GRAYLOCK AVETELEPHONE:
(323) 838-0006
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 4CENSUS: 3DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Memer Dellosa, AdministratorTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with Administrator, Memer Dellosa. The purpose of the visit was informed. The facility is licensed for (4) adults, ages 18 - 59 and is approved for 4 non-ambulatory clients.

The following domains were reviewed/inspected during today's visit:
Infection Control:
The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting daily and more often for high touched surfaces. Facility has sufficient PPE supplies and providing infection control practices update to staff as needed.
Physical Plant & Environment Safety:
The facility has 5 bedrooms (4 client bedrooms and 1 staff bedroom), 3 bathrooms, living room, kitchen with laundry area, dining room, second living room, and a detached garage. The backyard has a shaded patio and is furnished for clients use. There are no pools or bodies of water at the premises. The facility is well maintained with no items obstructing the passageways. The hot water temperature is measured within the required range of 105-120 degrees F.
Operational Requirements:
The facility is operating within the approved fire clearance. There are currently 3 ambulatory clients residing at the home and is vendorized by the Eastern Los Angeles Regional Center.
Food Service:
There are sufficient food supplies of 2-day perishable and at least a week of non-perishable items. Freezer is maintained at a temperature of 0 degree F and the refrigerator at a maximum of 45 degrees F. The foods are properly stored.
No deficiencies were issued today. An exit interview was held 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: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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