Community Care Licensing

Document Has Been Signed on 04/28/2022 01:03 PM - It Cannot Be Edited

FACILITY NAME:	ST MATTHEWS HOME FOR THE ELDERLY		FACILITY NUMBER:	198602197
ADMINISTRATOR:	CASTRO, SILVIA		FACILITY TYPE:	740
ADDRESS:	1004 NASHPORT DRIVE		TELEPHONE:	(909) 392-2266
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY: 6		CENSUS: 6	DATE:	04/28/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Staff / Reinalyn Martin		TIME COMPLETED:	01:15 PM

SUPERVISORS NAME: Wei Siew Ho LICENSING EVALUATOR NAME: Joe Katrdzhyan LICENSING EVALUATOR 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

Link to Parent Document Below:

FACILITY NAME: ST MATTHEWS HOME FOR THE ELDERLY	FACILITY NUMBER: 198602197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 04/29/2022 Section Cited CCR 87411(g)(2)	1 2 3 4 5 6 7	Personnel Requirements - General. Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will ensure individuals: Reinalyn Martin and Reginald Zaragosa are associated to St Matthews Home for the Elderly and provide proof to CCL by the POC due date. Civil Penalties were issued in the amount of $800.00
	8 9 10 11 12 13 14	During a complaint investigation conducted on 4/28/22, LPA discovered that individuals: Reinalyn Martin and Reginald Zaragosa have been working at the facility prior to requesting a transfer of a criminal record clearance	8 9 10 11 12 13 14
Request Denied Type A 04/28/2022 Section Cited CCR87411(g)(1)	1 2 3 4 5 6 7	Personnel Requirements - General. Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: Obtain a California clearance or a criminal record exemption as required by law or Department regulations. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Individual Orlando Placino left the facility at the time of this visit and will not return until he has obtained a California clearance or a criminal record exemption as required by law or Department regulations. A Civil Penalty was issued in the amount of $500.00
	8 9 10 11 12 13 14	During a complaint investigation conducted on 4/28/22, LPA discovered that individual: Orlando Placino has been working at the facility prior to obtaining a California clearance or a criminal record exemption as required by law or Department regulations. This poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Wei Siew Ho LICENSING EVALUATOR NAME: Joe Katrdzhyan LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022