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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602197
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:57:22 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
04/18/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220418144305
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:
04/28/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff / Reinalyn MartinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff not providing adequate service to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Reinalyn Martin who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Staff not providing adequate service to residents in care."

During today's visit, LPA interviewed Staff members 1 and 2 (S1 and S2) and Residents 1 through 5 (R1 - R5). LPA was unable to interview Resident 6 (R6) as R6 was observed sleeping at the time of this visit.

The investigation revealed the following;
Allegation: Staff not providing adequate service to residents in care. The details of this allegation states that for the last couple of months, residents have not been bathed and diapers not being changed.

(Please see LIC 9099C for additional information)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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-20220418144305
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: 04/28/2022
NARRATIVE
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Based on interviews conducted the statements obtained were inconsistent and did not corroborate with the allegation. Residents interviewed confirmed that residents are given a shower/bath three times a week and diapers are changed three times a day (morning, afternoon and before bedtime) or as needed.
Statements obtained from staff corroborated with the statements obtained from residents. LPA learned that some residents receive baths from nurses from outside agencies and in the event that an outside agency nurse is not able to visit the facility, facility staff will proceed to give the resident(s) a bath. Based on the information gathered, there is insufficient evidence to support the allegation to be true.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2