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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602197
Report Date: 06/11/2021
Date Signed: 07/06/2021 03:58:55 PM

Document Has Been Signed on 07/06/2021 03:58 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: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
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Caregiver, Maria PelkyTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Linda Almaraz conducted an annual required visit at the facility above. LPA met with Caregiver, Maria Pelky and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications and observed food supply. Facility has submitted a mitigation plan and pending approval.

The facility is a 4 bedroom, 3 bathroom (1 bathroom for staff/visitors) home located in a residential neighborhood. Facility has a main entry point for screening. All 6 residents bedrooms were toured. Each bedroom had required furniture and equipment. All bathrooms were toured and the toilets, hand washing and showers are safe and sanitary. Bathrooms had hand soap. The food in the kitchen was sufficient supply of 2 days perishable and 7 days non-perishable. The common areas such as living room and dining area are clean and have the required furniture. The backyard has a shaded area and sitting area. Medications are centrally stored, locked along with the records. Carbon monoxide and smoke alarm detectors were tested and working.

Water temperature in both bathrooms were not within required range of 105-120 degree F. Bathroom #1 was reading at 129 degree F and bathroom #2 125 degree F.

Deficiencies cited under California Code of Regulations Title 22

An exit Interview was conducted with the Administrator via telephone and a hardcopy was provided to the caregiver. Appeal rights were provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2021 03:58 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 06/11/2021 at 12:32 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: ST MATTHEWS HOME FOR THE ELDERLY
FACILITY NUMBER: 198602197

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by: LPA and staff member Maria Pelky observed water temperature in bathroom #1 reading at 129 dregrees F and bathroom #2 reading at 125 degrees F.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 3 bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2021
Plan of Correction
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Administrator shall adjust water temperatures for the whole facility to be within regulation limits of 105-120 degree F. Administrator will document temperature readings for 7 days and will send proof to LPA via email or fax by POC due date.
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:Christine Yee
LICENSING EVALUATOR NAME:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2021


LIC809 (FAS) - (06/04)
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