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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803160
Report Date: 07/26/2024
Date Signed: 07/26/2024 05:25:05 PM

Document Has Been Signed on 07/26/2024 05:25 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 VFACILITY NUMBER:
197803160
ADMINISTRATOR/
DIRECTOR:		PALISOC, ADORACIONFACILITY TYPE:
735
ADDRESS:1015 SAINT MALO ST.TELEPHONE:
(626) 939-4234
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 6CENSUS: 4DATE:
07/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Santiago BettinaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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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 4 clients residing at the home and receive services from San Gabriel / Pomona regional Center. LPA toured the home and inspected 3 clients rooms and 2 live-in staff rooms, 2 bathrooms, 1 office / supply room, living room, dining area, family area, kitchen, and attached garage. The laundry room is located in the back area. There is a shaded seating area for the clients located in the backyard. Inflatable pool with the water was observed in the backyard of facility accessible to clients. Laundry was observed in the back of the house. LPA observed laundry detergent unlocked in the laundry and accessible to clients. LPA observed several empty bags from construction materials, wood pallets, empty paint containers blacking walkways 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 in both bathrooms and was measured 112.2 degrees and 114.1degrees, 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. LPA observed cleaning supplies unlocked under the sink.

Continue 809C.


SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 07/26/2024 05:25 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/26/2024 at 03:18 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: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) 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.

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 2 big plastic boxes in the midlle of family room a full with various items and facility was dusty, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Boxes removed from the family area and staff clean the dust and vacuumed the facility. Licensse will ensure that the facility is clean at all the time. Cleared at the time of visit.
Type A
Section Cited
CCR
80087(e)
Building and Grounds
(e) All licensees serving children or serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water through a pool cover or by surrounding the pool with a fence.

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 inflatable pool (96In.DIA X 30In H) full of the water in the backyard accessible to the clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Administrator emptied the pool, deflated, folded and put in the garage. Cleared at the time of visit.
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: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/26/2024 05:25 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/26/2024 at 03:18 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: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building 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. LPA observed gallon of Clorox, Easy Off cleaner, Laundry detergent unlocked under the kitchen sink and in the laundry area, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Cleaning solutions were locked immediatly. Cleared at the time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/26/2024 05:25 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/26/2024 at 03:18 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: 07/26/2024

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 empty bags from constructions materials and wood pallets, empty paint containers in the back of the facility 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: 07/30/2024
Plan of Correction
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Licensee will remove all debris / obstructions and send the picture to LPA.
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: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
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 V
FACILITY NUMBER: 197803160
VISIT DATE: 07/26/2024
NARRATIVE
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2 Fire extinguisher observed in the facility fully charged. Carbon monoxide/smoke detectors in the hallways are 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: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5