197803160-9-19-2023-28-AS-KRAZ-CVTUPM-20230919154545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803160
Report Date: 09/19/2023
Date Signed: 09/19/2023 03:46:02 PM

Document Has Been Signed on 09/19/2023 03:46 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 V		FACILITY NUMBER:	197803160
ADMINISTRATOR:	PALISOC, ADORACION		FACILITY TYPE:	735
ADDRESS:	1015 SAINT MALO ST.		TELEPHONE:	(626) 939-4234
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY: 6		CENSUS: 5	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Staff #1		TIME COMPLETED:	03:40 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 09/19/2023 at 9:00 am. LPA Ramirez was met by staff #1 (S1) explained the purpose of the visit. The facility is licensed serve six (6) developmentally disabled clients 18-59 years old, of which four (4) may be non-ambulatory. The facility is a level 4C home. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Client Roster (LIC 9020).

LPA OBSERVATIONS: Tour began at 9:11 am and was led by S1. The facility is a single-story building located in a residential area with four (4) client bedrooms, two (2) staff bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, front yard, backyard.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed appliances to be in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to five (5) out of five (5) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to five (5) out of five (5) clients in care. LPA Ramirez observed a fully charger fire extinguisher nearby.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed with plenty of lighting. LPA Ramirez observed several boxes with various items, stacked in corners of the living room area. Per S1, the facility was recently painted, and the facility is moving boxes around in order to paint and do light cosmetic work on the facility. LPA Ramirez will issue Technical Advisory. LPA Ramirez observed a fully charged fire extinguisher nearby. LPA Ramirez observed signage promoting cough and handwashing etiquette in this area.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Client Rooms 1 - 4: LPA Ramirez observed all client bedrooms to contain the required linens, furnishings, and lighting.

See 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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 V	FACILITY NUMBER: 197803160
	VISIT DATE: 09/19/2023

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Bathroom 1-2: Water temperature in client bathroom#1 was measured at 114.6 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed signage promoting proper handwashing etiquette near sink. Water temperature in client bathroom#1 was measured at 107.8 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed signage promoting proper handwashing etiquette near sink. LPA Ramirez observed locked cabinet in this bathroom that contained extra hygiene supplies and toiletry items.

Centrally Stored Medications: LPA Ramirez observed medications to be locked in file cabinet located in kitchen area.

Backyard: No large bodies of water were observed. LPA Ramirez observed construction like debris including, ladder, several paint cans, paint brushes and paint rollers, paint tray, various empty cardboard boxes, and a large couch with tears and rips in seating area, were all observed on the side of the facility and patio area. LPA Ramirez will issue Technical Advisory.

Garage: LPA Ramirez observed emergency water supply, emergency food supplies and PPE in this area. Facility staff keep extra toiletry supplies in this area.

Emergency Drills (Conducted every 6 months): Proof of last documented drill was 6/9/23 at 10 am.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Staff Personnel Files: Staff files were maintained at facility. LPA Ramirez reviewed four (4) out of the four (4) staff that were present during inspection. LPA Ramirez reviewed four (4) staff files. LPA Ramirez verified Administrator Certificate for Bettina Grace T Santiago is currently being processed for renewal.

Client Files: Five (5) client files were reviewed.

Infection Control Plan: LPA Ramirez obtained copy of Infection Control Plan.

Deficiency is being cited. Two (2) Technical Violations were issued during the visit. Exit interview was conducted with S1 and a copy of this report, 809-D, LIC 9102 TV, and appeals rights were provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2023 03:46 PM - It Cannot Be Edited

Created By: Kimberly Ramirez On 09/19/2023 at 01:37 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: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.4(g)

(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. This requirement is not met as evidenced by: Five (5) out of five (5) clients are over the age of 60 and facility does not have any approved age exceptions on file.
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 5 clients do not have age exception waivers, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/03/2023
	Plan of Correction
1 2 3 4	Licensee will submit to this licensing agency: Documentation of a medical assessment, signed by a physician, made within the last year, A letter of support from the person's conservator with placement authority, if applicable, letters of support, if any, from the person's placement officer, social worker, and/or mental health professional, if applicable, documenting that the current facility is the most appropriate setting for the person. Must submit via email by 10/3/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Kimberly Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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