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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602197
Report Date: 04/15/2024
Date Signed: 04/15/2024 04:56:12 PM

Document Has Been Signed on 04/15/2024 04:56 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST MATTHEWS HOME FOR THE ELDERLYFACILITY NUMBER:
198602197
ADMINISTRATOR/
DIRECTOR:		CASTRO, SILVIAFACILITY TYPE:
740
ADDRESS:1004 NASHPORT DRIVETELEPHONE:
(909) 392-2266
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 6CENSUS: 6DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:03 PM
MET WITH:Licensee Terry McgeeTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 04/15/2024. LPA was met by Licensee Terry Mcgee and explained the purpose of the visit. Facility is licensed to residents 60 years old and above. The facility is approved for 1 bedridden and 6 non-ambulatory. The facility may retain two (2) hospice residents. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020) and copy of liability insurance.

LPA OBSERVATIONS: The Facility is a single-story building in a residential area with four (4) resident bedrooms, three (3) shared bathrooms, kitchen, dining room, living room, den/tv room, front yard, backyard and attached car garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables.

Dining Room/Living room/Den/TV room: Dining room was observed to be clean and contained table and 5 chairs. Living room area has plenty of seating for residents and guests. Den/Tv room was observed to be clean and contained plenty of seating.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms 1 - 4: All contained the required furnishings, linens and were observed to be clean.

See 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ST MATTHEWS HOME FOR THE ELDERLY
FACILITY NUMBER: 198602197
VISIT DATE: 04/15/2024
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Bathrooms 1-3: Resident bathroom# 1 was observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Grab bars were observed near toilet and shower. Water temperature in this bathroom were measured to be within the required 105 – 120 degrees F. Shared resident bathroom #2 water temperature was measured to be within the required 105 – 120 degrees F. Grab bars were observed near toilet and shower. Resident bathroom #3 only has a toilet and sink. Water temperature in this bathroom was measured within the required 105-120 degrees F.

Centrally Stored Medications: LPA’s observed hallway closet located near entry to be locked and inaccessible to residents.

Attached Garage: LPA observed extra bedding supplies, cleaning products and hygiene products. Garage was locked and inaccessible to residents.

Backyard: Clean and free from hazards. LPA observed plenty of seating and shaded area.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. LPA observed auditory sensors on front door and sliding door. Administrator certificate was observed for Deborah Davis with an expiration date of 01/15/2025.

No deficiencies are being cited. Exit interview was conducted with Licensee Terry Mcgee and a copy of this report was provided via email due to printer problems.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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