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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803160
Report Date: 11/15/2022
Date Signed: 11/15/2022 04:26:25 PM

Document Has Been Signed on 11/15/2022 04:26 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 VFACILITY NUMBER:
197803160
ADMINISTRATOR:PALISOC, ADORACIONFACILITY TYPE:
735
ADDRESS:1015 SAINT MALO ST.TELEPHONE:
(626) 939-4234
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 6CENSUS: 5DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:John Beltran, StaffTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the infection control domain. LPA was allowed entry by Staff, John Beltran, and the purpose of the visit was explained. The facility is licensed for 6 developmentally disabled adults, ages 18 to 59, and of which 4 may be non-ambulatory. There are currently 5 clients residing in the home and receive services from the San Gabriel/Pomona Regional Center.

LPA toured the facility and observed the following:
* There are 5 bedrooms (3 for clients and 2 for live-in staff), 2 bathrooms, living room, dining room, family room, kitchen, and an attached garage. The laundry room is located in the back yard area.
* Covid-19 signage are posted throughout the home. Hand washing signs are posted in the bathrooms.
* PPE station is set up by the front door. Extra PPE supplies are stored in the shed.
* The facility documents temperature of visitors, staff, and clients.
* Food supplies of 2 day perishable and a week of non-perishable are observed.
* The smoke detectors and a carbon monoxide detector are operable.
* Medications are centrally stored and locked in the kitchen cabinet. LPA reviewed all 5 clients' medications and the medications are being administered as prescribed.
* All 5 client files have updated emergency information. The emergency contact information for other agencies are posted for staff.
* Interviews were conducted with the 3 Staff.
* Staff were wearing a face mask.
* Staff stated they clean at least once a day. Cleaning solutions are stored in the laundry room. During the tour, LPA observed the laundry room open and cabinets with chemicals were unlocked, making them accessible to clients.
A deficiency was cited on the LIC809D page. An exit interview was held. A copy of this report along with appeal rights were given to Staff Rolando Manalad.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
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 11/15/2022 04:26 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 11/15/2022 at 04:06 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 V
FACILITY NUMBER: 197803160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.


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 in that the cabinets in the laundry room containing chemicals were unlocked which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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The licensee shall ensure the chemicals/cleaning solutions are properly stored and locked at all times. The licensee shall develop a plan to ensure that the staff are locking the chemicals after use. The POC is due on 11/18/22.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022


LIC809 (FAS) - (06/04)
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