Community Care Licensing

Document Has Been Signed on 02/13/2024 03:40 PM - It Cannot Be Edited

FACILITY NAME:	MIDOMAR HOMES III		FACILITY NUMBER:	197800590
ADMINISTRATOR:	CARLOS A. LOPEZ		FACILITY TYPE:	735
ADDRESS:	2032 GRAYLOCK AVE		TELEPHONE:	(323) 838-0006
CITY:	MONTEREY PARK	STATE: CA	ZIP CODE:	91754
CAPACITY: 4		CENSUS: 3	DATE:	02/13/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Memer Dellosa, Administrator		TIME COMPLETED:	03:58 PM

SUPERVISORS NAME: Lisa Hicks LICENSING EVALUATOR NAME: Alberto Lopez LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024

Link to Parent Document Below:

FACILITY NAME: MIDOMAR HOMES III	FACILITY NUMBER: 197800590
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/16/2024 Section Cited CCR 80061(b)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements. Reports are required for any injury to any client which requires medical treatment. During today's visit, LPA discovered that there have been multiple incidents involving Client #1 which required medical attention and the incidents were not reported to CCL as required per Title 22 Regulations. This deficiency is evidenced by:	1 2 3 4 5 6 7	Administrator will review Title 22 Regulations Section 80061 and have an In-service training with all Staff regarding Reporting Requirements. Administrator will submit a written plan ensuring that incidents are reported to the CCL office as required according to the Regulation. Signatures of all Staff from the training must be submitted to CCL along with the written plan.Also, facility will send incident reports for the 4 missing dates to CCL. The plan is due by the POC date of 2/16/2024 .
	8 9 10 11 12 13 14	Facility failed to report to CCL 4 incidents: Reports are missing for C1 for the dates of 01/24/2023 when C1 was sent home early from day program, 01/26/2022 when C1 was first hospitalized, 01/28/2024 when C1 was taken to ER at Monterey Park Hospital 02/01/2024 and when C1 was taken and admitted to White Memorial Hospital.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

SUPERVISOR'S NAME: Lisa Hicks LICENSING EVALUATOR NAME: Alberto Lopez LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024