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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197800590
Report Date: 02/15/2024
Date Signed: 02/15/2024 11:46:35 AM

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
02/07/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240207124807
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:
02/15/2024
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Memer Dellosa, Administrator TIME COMPLETED:
11:52 AM
ALLEGATION(S):
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Staff did not prevent resident from developing pressure injuries while in care.
Staff are over-medicating a resident in care.
INVESTIGATION FINDINGS:
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LPA made a subsequent unannounced visit to deliver findings and was greeted by DSP Rafaelita Deasa who allowed entry and Administrator Memer Dellosa arrived a short time later. LPA explained the purpose of the visit. LPA took tour of facility.
On initial visit on 02/13/2024 LPA completed:

The investigation consisted of Interviews with 2 staff S#1-S#2, 4 Witnesses #1-#4, and 2 clients. LPA reviewed C1 IPP dated 01/31/2023, DCS notes for 01/13/2024 to 02/01/2023, Fax from PCP dated 01/26/2024 with lab results. Fax to Dr Wong, Psychiatrist dated 02/01/2024 sent by S1 and Dr. Wong response to S1. SIR sent to East Los Angeles Regional Center dated January 29, 2024 and February 2, 2024. LPA reviewed C1 face sheet, Medical Specialist report dated 01/09/2024, 11/14/2023, 12/01/2022 7/26/2021, Discharge instructions from Downtown Los Angeles UCC dated 1/26/2024, C1 MAR for January and Partial Month of February 2024, copy of face sheet, Current IPP dated 01/25/2024, DCS notes ranging from 01/19/2024 – 02/13/2024.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
02/07/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240207124807

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:
02/15/2024
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Memer TIME COMPLETED:
11:52 AM
ALLEGATION(S):
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Staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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Allegation: Staff did not seek medical attention in a timely manner. It is alleged that staff did not seek medical attention in a timely manner. According to S1, C1 was experiencing weakness and loss of appetite beginning 01/25/2025. S1 stated he offered C1 food that C1 liked and ate the food. S1 stated C1 looked sad. S1 asked C1 what was wrong, and C1 did not answer. C1 last attended day program on 01/24/2024. On 01/25/2024 S1 stated that C1 was sad and did not want to go to the day program. W2 arrived at 4:00PM to update IPP for C1 on 01/25/2024. C1 was quiet during the visit and just listening to us. On 01/26/2024, S1 asked C1 if C1 wanted to go to urgent care because C1 was not doing C1 routine, refused to shower at and C1 stated yes. S1 stated he asked C1 because C1 did not want to do C1 routine and suspected C1 was not doing well. S1 took C1 to Downtown, Los Angeles, UCC and C1 was sent home, but it was recommended that C1 go to ER and get further evaluation and LABS. S1 stated that C1 refused to go. (No evidence of C1 refusal) S1 told urgent care on 01/26/2024 and that C1 was experiencing weakness and having trouble walking for 5 days or beginning on 01/22/2024. S1 stated that he did not take C1 to hospital before 01/26/2024 due to C1 being in “jolly” mood upon C1 return from the day program on 1/24/2024.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240207124807
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 III
FACILITY NUMBER: 197800590
VISIT DATE: 02/15/2024
NARRATIVE
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On documentation from Urgent Care dated 1/26/2024, it is documented that C1 had not been able to walk steady since 01/22/2024 and was experiencing overall weakness. S1 stated he contacted C1’s PCP on the January 25, 2024 and lab results for lithium was high and PCP asked S1 to contact C1 psychiatrist right away. W3 (Day Program Supervisor) stated that they asked facility administrator, S1 to send C1 for evaluation on 01/24/2024 in an email dated 01/24/2024 at 1:56PM. (LPA was forwarded email from day program) S1 started that he did not get the email because it was wrong email address but that Program Manager W4 called on 01/24/2024 at 1:05PM and spoke with S1 expressing her concerns about C1. W4 stated to S1 that they are going to send C1 home early because C1 is not feeling well. S1 stated that when C1 arrived C1 looked sad but was doing C1 usual activity of watching TV and S1 stated S1 didn’t feel that C1 required medical attention at that time, so he did send C1 to the hospital or call C1 primary doctor on January 24, 2024. The fact that C1 was sent home early from the day program on 01/24/2024, and facility, as well as Regional Center Service Coordinator Dora Contreras being alerted via email at 1:56PM on 1/24/2024 by Day Program Manager (W4) asking facility staff to have C1 evaluated by C1 doctor and requesting a note from C1 PCP to allow C1 to continue to participate at day program without restrictions clearly shows that facility failed to get timely medical attention for C1. Facility was alerted on 01/24/2024 by day program to have C1 evaluated by his PCP and C1 was not taken to hospital until 01/26/2024 shows that C1 did not get timely medication. There is sufficient evidence to substantiate this allegation.
Based on LPAs interviews and conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 3 are being cited on the attached LIC 9099D
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20240207124807
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 III
FACILITY NUMBER: 197800590
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2024
Section Cited
CCR
80075(a)
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80075(a) Health Related Services. Each client shall receive necessary first aid and medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement is not met evidenced by:
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POC The facility shall comply with state regulations in meeting the medical needs of all clients. The facility shall develop a procedure to follow when staff observe that a client's health needs a medical assessment from a medical professional to ensure that medical attention is provided in a timely manner. Facility is to ensure that Title 22 Section 80075 regulations are met at all times. Additionally, an in-service training is to be conducted regarding Title 22 Section 80075 and a training log with staff signature submitted to CCLD by 02/19/2024
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C1 was not provided medical care for more than 48 hours(From 01/24/2024 until 01/26/2024) after Day Program Personnel had concerns about C1 health and asked facility to have C1 evaluated and have C1 MD provide clearance that C1 is able to attend day program without restrictions.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240207124807
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 III
FACILITY NUMBER: 197800590
VISIT DATE: 02/15/2024
NARRATIVE
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The investigation revealed:

Allegation: Staff did not prevent resident from developing pressure injuries while in care. It is alleged that resident developed a pressure injury while in care. LPA interviewed 2 staff and 2 of 2 staff denied the allegation. S2 stated that it is allergy and had been treated for it. S1 stated that it is skin pigmentation only and not a pressure injury. LPA interviewed W1 and W1 stated that his initial analysis was wrong and that is not a pressure injury and was not treated for any pressure injury. Current hospital documentation did not mention any kind of pressure injury nor described any treatment for such. LPA interviewed W#3 an W#4 from day program and they both stated they did not observe any pressure injuries on C1. There is not evidence that C1 suffered a pressure injury while in care.

Allegation: Staff are over-medicating a resident in care. It is alleged that facility is over medicating resident. C1 arrived at White Memorial Hospital on 02/01/2024 and was admitted. Test results from White Memorial Hospital indicated that C1 lithium levels were 2.0 (toxic range per reference > 1.5). C1 was given 2 doses of lithium up until 02/01/2024 and it was administered according to doctors orders. The facility did not have any orders from C1 doctors to decrease or stop the Lithium, so the facility continued to administer up to the day C1 was admitted. C1 lithium was discontinued at the hospital and C1 has slowly recovered. Even though C1 levels of lithium were high at the time at admittance, there is no evidence that the facility gave C1 more than what his doctor ordered. LPA inspected C1 medication, the MAR for January and February 2024, and the lithium was given according to doctor’s orders. There is no evidence that the facility over medicated C1.

Based on LPA's interviews, and document reviewed, the investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Memer Dellosa and a copy of this record provided.

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

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5