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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800590
Report Date: 09/30/2025
Date Signed: 09/30/2025 04:04:47 PM

Document Has Been Signed on 09/30/2025 04:04 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/
DIRECTOR:		CARLOS A. LOPEZFACILITY TYPE:
735
ADDRESS:2032 GRAYLOCK AVETELEPHONE:
(323) 838-0006
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY: 4CENSUS: 1DATE:
09/30/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:08 PM
MET WITH:Memer Dellrosa, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:14 PM
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to follow up on death of client.

C1 was transported to Monterey Park hospital on 09/19/2025. Administrator stated he observed client to be tired and sad. Also, day program staff told Administrator that client had bad appetite for about 2 weeks and was declining to eat. Administrator stated client was eating normally until 09/19/2025. In the afternoon on 09/19/2025 during dinner time, client refused to eat regular food but eat blended food At 7:00 pm. Administrator observed client sad and weak and contacted his physician and his physician asked to take client to emergency room. At that time Administrator spoke with conservator/mother and she transferred to her daughter to translate. Mother agreed for staff to transport client to hospital. Client arrived at 7:45pm at the emergency room 09/19/2025. Client underwent tests and was sedated until 6:00 am for blood sample. Client was transfer to regular bed in room 104 on 09/20/2025 at around 7:55am. Client was sedated until Sunday 09/21/2025 and opened his eyes at around 9:00 am and he appeared better and recognized administrator and other staff and even leaned his face on hand of Administrator. Administrator thought he was ok. After that, Administrator stated he visited Monday morning at around 09:00 am and observed client intubated and sister who was spend the night with client told administrator that client suffered massive seizure overnight. On 09/23/2025, client was transferred to ICU and Administrator arrived at around 10:00am that day. Client was observed with difficulty breathing and on 09/26/2025 client passed at 1:29am.

LPA took tour of facility, interviewed administrator and one (1) client. LPA did not observed any health or safety concerns during visit. No signs of foul play observed.

No deficiencies observed or cited. Exit interview conducted with Administrator and copy of report provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
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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