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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802648
Report Date: 04/04/2024
Date Signed: 04/04/2024 04:16:06 PM

Document Has Been Signed on 04/04/2024 04:16 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MIDOMAR HOME IVFACILITY NUMBER:
197802648
ADMINISTRATOR/
DIRECTOR:		PALISOC, ADORACTIONFACILITY TYPE:
735
ADDRESS:1129 S. AVINGTON AVE.TELEPHONE:
(626) 917-5779
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 3DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Santiago BettinaTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Assistant Administrator Santiago Bettina who assisted with the visit. LPA explained the reason for the visit.

The physical plant was inspected along, medications, food supply, and resident and staff records. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and vendorized by San Gabriel/Pomona Regional Center. There are currently 3 clients residing at the home and receive services from San Gabriel / Pomona regional Center. LPA toured the home and inspected three (3) client bedrooms, two (2) client’s bathrooms, kitchen, dining room, family room, living room, and attached garage. The front yard is well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Laundry was observed in the back of the house. LPA observed laundry detergent locked in the laundry and not accessible to clients. There is only one entrance being utilized at the facility. There is a fireplace located in the living room area which is covered by a screen.


LPA observed old wheelchairs, commode chairs, old glass - aquarium, 2 plastic boxes and big black trash bag full of trash blacking walkway in the backyard of house. Client bedrooms were checked. Each bedroom has bed, linen, dresser, light, and sufficient closet space. The client bathrooms were toured. Bathrooms have the required hygiene items, grab bars and non-skid mat. The hot water temperature was tested and was measured 109.2 degrees, which is within the required 105 - 120 degrees. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked in a kitchen cabinet inaccessible to clients.

Continue 9099C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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Document Has Been Signed on 04/04/2024 04:16 PM - It Cannot Be Edited


Created By: Nune Margaryan On 04/04/2024 at 03:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MIDOMAR HOME IV
FACILITY NUMBER: 197802648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed old wheelchairs, commode chairs, old glass - aquarium, 2 plastic boxes and big black trash bag full of trash blacking walkway in the backyard of house , which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Licensee will ensure to clean the backyard and keep it clean at all the time. Pictures will be send to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MIDOMAR HOME IV
FACILITY NUMBER: 197802648
VISIT DATE: 04/04/2024
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Fire extinguisher observed in the hallway fully charged. Carbon monoxide/smoke detectors in the hallway and in the client rooms operational. Centrally stored medications are stored in a locked cabinet in the kitchen. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Deficiency is being cited. See LIC 809D.


Exit interview was conducted with Santiago Bettina. A copy of the report/appeal rights was issued.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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