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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802648
Report Date: 03/30/2023
Date Signed: 03/30/2023 04:29:48 PM

Document Has Been Signed on 03/30/2023 04:29 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 HOME IVFACILITY NUMBER:
197802648
ADMINISTRATOR:LOPEZ, CARLOSFACILITY TYPE:
735
ADDRESS:1129 S. AVINGTON AVE.TELEPHONE:
(626) 917-5779
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 4DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Bettina Santiago TIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Christine Wong and Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with House Manager Irene Leonor allowed the entry of the facility. Shortly after, LPA met with the Assistant Administrator Bettina Santiago and assisted with the visit. The purpose for the visit was explained. The facility is licensed for 2 non-ambulatory only - licensed can only serve developmentally disabled adults age 18 through 59.

LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and inspected these domain:
Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting at least once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan.
Physical Plant and Environmental: The facility is a single story house and located in a residential neighborhood area. The house include: four clients bedrooms, two clients bathrooms, two live in staff rooms, kitchen, dining area, sitting room, family room/living room, staff office and an attached garage. All clients bedrooms have the required furniture and beddings. All bathrooms are clean, sanitary and in a good working condition. All the sharp knives and utensils and chemicals are locked and inaccessible to clients. All the clients personal hygiene are stored in the hallway cabinet. LPA inspected the carbon monoxide detectors and smoke detectors and they are all working properly. LPA tested the hot water in the facility and they were tested between 107 and 107.5 degrees F which is is within the Title 22 regulation.
Operational Requirements: The facility currently has 4 clients and they are all ambulatory and its within maintained the fire clearance approved by the city. The facility also has a shaded area with table and chairs in the patio for clients to utilize.
Staffing: The facility has sufficient staffing in the facility and the night supervision staff has the required training for planned emergency procedure training.
(See LIC809C for continuation)


SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 HOME IV
FACILITY NUMBER: 197802648
VISIT DATE: 03/30/2023
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Personnel Record- The staff files are maintained in the facility. All the staff has the updated first aid training. All the staff are background check cleared and associated with the facility. The administrator (Adoracion Palisoc) certificate expired on 3/26/23 but LPA checked on CCL system and the administrator certification is pending and was received 03/16/23.
Client Right-Information: The facility does not have any client with postural support. The facility would serve clients has internet services and provide at lease one internet access device
Client Records-Incident Reports: The client files are maintained in the facility. All the clients files have the required documents in the file which include: Face sheet, admission agreement, Individual Personal Plan (IPP) and physician report.
Food Service: The facility has 2 days perishable and 7 days non-perishable food supply. The facility refrigerator is maintained in a required temperature. All the food in the refrigerator are stored probably.
Health Related Services: All the client's medication are centrally stored in the kitchen cabinet and its inaccessible to clients. All the client's medication are seemed accurate and updated. All the staff also have an updated Medication Management training.
Incidental Medical Services: Currently the facility has no client with restricted health condition or prohibited health condition.
Disaster Preparedness: The facility has an updated Emergency and Disaster Plan (LIC610D) posted with contact numbers and at least two alternative location.
Emergency Intervention: All the staff have the CPI training and it's up-to-date.

On today's visit, LPA interview three staff and two clients in the facility.

No deficiencies were issued today. An exit interview was held. A copy of this report was given to the Assistant Administrator Bettina Santiago



SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
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