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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602197
Report Date: 06/11/2021
Date Signed: 06/11/2021 03:49:41 PM

Unsubstantiated


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
06/16/2020 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20200616084246
FACILITY NAME:ST MATTHEWS HOME FOR THE ELDERLYFACILITY NUMBER:
198602197
ADMINISTRATOR:CASTRO, SILVIAFACILITY TYPE:
740
ADDRESS:1004 NASHPORT DRIVETELEPHONE:
(909) 392-2266
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:6CENSUS: 6DATE:
06/11/2021
UNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Caregiver, Maria PelkyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not ensure that resident's catheter needs were met.
Night staff are not accessible to residents
Medications were accesible to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint visit for the allegations listed above. LPA met with Caregiver, Maria Pelky and explained the reason for todays visit. Licensee, Terry McGee later arrived at the facility

The investigation consisted of the following: On 6/19/20 at approximately 2:45 PM, LPA Almaraz conducted an interview with the Administrator Silvia Castro, Licensee, Staff #1 and attempted to interview Staff #2. LPA requested and received copies of: Staff and Resident Roster, Staff schedule/time sheets and Residents #1-2 files. Documents were received by fax. On 6/11/21, LPA interview Staff #3-4 and Residents #1-4 and attempted to interview resident #5 via telephone at their new facility but was unsuccessful.

The investigation revealed the following: Interviews conducted with staff indicated when they had a resident who had a catheter they would always empty the catheter bag if it was full. Interviews revealed they would not change the bag or tubing since only a skilled professional can do it. (Continued on an LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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 2
Control Number 28-AS-20200616084246
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: ST MATTHEWS HOME FOR THE ELDERLY
FACILITY NUMBER: 198602197
VISIT DATE: 06/11/2021
NARRATIVE
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Interviews with staff and residents revealed if a resident needs assistance at night they are attended immediately. There is 1 (one) resident who has a call monitor because the resident has a very low voice. All residents indicated they have never not been attended during the night and are changed frequently during the night and day time.

LPA interviewed staff and residents regarding medication being accessible and all interviews conducted indicated medication has never been seen unlocked or out of the medication cabinet. LPA did not observe any medication out in rooms or the facility. LPA checked medication cabinet and it was locked and secure.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted with Licensee and a hardcopy was provided.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2