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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602197
Report Date: 06/10/2022
Date Signed: 06/10/2022 05:30:53 PM

Document Has Been Signed on 06/10/2022 05:30 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: 5DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Reinalyn J Martin, Staff
Silvia Castro, Administrator		TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with staff, Reinalyn Martin, who assisted with the visit. LPA spoke with Administrator, Silvia Castro over the phone and explained the purpose of today's visit. Administrator joined the visit at around 4:30pm. Facility is licensed to serve six (6) non-ambulatory residents, age 60 and above, of which one (1) maybe bedridden. Annual licensing fee is current. Administrator certificate is current and the expiration date is 10/14/22. Facility has hospice waiver for two (2). Currently, four (4) hospice residents residing at the facility.

During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.



The facility is a single story house located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. The facility consisted of 4 residents bedroom, 2 1/2 bathrooms, dining room, kitchen, TV/living room, and family room. Facility has a main entry point for screening. All four residents bedrooms were toured. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 112.1 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. No firearms on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely.

( - continued in LIC 809 C-)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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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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: ST MATTHEWS HOME FOR THE ELDERLY
FACILITY NUMBER: 198602197
VISIT DATE: 06/10/2022
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Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. A dual device of Smoke detectors combined with carbon monoxide detectors are tested and operable. Fire extinguishers’ last service is 4/15/22 and are fully charged.

The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked storage room and inaccessible to residents. Resident records are stored in a locked storage room and inaccessible to residents. Toxic substances are inaccessible to residents.

Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents. A copy of appeal rights was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2022 05:30 PM - It Cannot Be Edited


Created By: Bonnie Tao On 06/10/2022 at 04:51 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: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(a)
Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department.


This requirement is not met as evidenced by:
Facility has approved of two (2) hospice waivers. Currently, facility has four (4) residents on hospice residing at the facility. Administrator did not apply hospice increase request to Licensing to apply for 2 more hospice waviers.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above regulation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2022
Plan of Correction
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Administrator will submit a request to Licensing and related documents to apply for hospice waiver requests by POC 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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


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