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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802648
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:32:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/08/2024 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20240108102949
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: 3DATE:
01/11/2024
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Irene LeonorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not ensure facility was free from pests.
Staff did not clean the residents room.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted an initial complaint visit to investigate the above allegations.LPA met with Irene Leonor who called Assistant Administrator and notified about the visit. Assistant Administrator arrived shortly after. Purpose of visit was explained.

During today's visit, LPA toured the physical plant including the living room, kitchen, office, clients rooms, clients bathrooms and backyard. LPA also obtained a copy of invoice/customer service report from
TermiGone extermination, INC. company and interviewed Staff 1 (S1) and staff 2 (S2). At the time of visit LPA met with C1's conservator at facility and obtained pictures and videos related to the complaint.

See LIC9099C


Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
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 3
Control Number 28-AS-20240108102949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/11/2024
NARRATIVE
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Allegation 1: Staff did not ensure facility was free from pests. It was alleged that rat feces observed under the clients bed.
S1 states that on 01/03/24 S2 informed them that rats feces observed in C1's room. S1 states that staff and clients never complain about rats and the facility didn't have an exterminator treat until 01/04/24. Facility contacts the pests control company at the same day 01/03/2024 and on 01/04/24 facility was treated by the TermiGone Extermination INC. company. LPA obtained a copy of invoice/report from the company. On the customer service report dated on 01/04/2024, the service specialist noted the following: rodents activity found at the facility. Also found 2 entry points for rodents and they need to be re-screened. Per report 6 glue boards were set-up in the office, kitchen, and adjacent rooms. LPA toured the facility and observed 3 glue boards in the kitchen: 2 on the left side of stove and one on the right side of stove, 2 glue boards in the hallway under cabinet and 1 glue boards in the office under the desk. LPA also found the rat feces in C1's room under the bed. Pictures were taken by LPA. Assistant Administrator stated that they will be in contact with the company regularly until get rid of this problem.

Allegation 2: Staff did not clean the clients room. It was alleged that clients room was dirty, filthy and staff had not been cleaning the rooms. At the time of visit LPA toured the facility including the living room, kitchen, office, clients rooms, clients bathrooms and backyard. LPA observed rodents feces in C1's room under the bed (picture was taken by LPA). LPA also observed that 2 entry points in sub-area that mentioned on the pests control company's report not re-screened yet. Interviewed staff stated that the facility staff clean clients rooms daily, and deep cleaning 2 times a mouth. At the time of visit LPA noticed that facility was not dirty, filthy, however obtained pictures and videos from C1's conservator showed that C1's clothing on the floor in the closet, dust on the floor and on the moldings in the room, dust and rodents feces under the bed.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore, the above mentioned allegations are found to be substantiated and citations issued.


See attached LIC9099D

An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240108102949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2024
Section Cited
CCR
80087(a)(1)
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Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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This regulations was not met by
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Administrator will be in contact with the exterminator until to get rid of this problem. Administrator will provide LPA invoices of Exterminator treating the rodent problem.
Licensee will make sure that staff will keep the facility clean.
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LPA observed rodents dropping in the client room. LPA observed 6 glue boards at the facility(by the service specialist). 2 entry points in sub-areas are not re-screned. LPA obtained the pictures and videos shows that client room is dirty.
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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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3