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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602876
Report Date: 11/03/2022
Date Signed: 11/03/2022 11:21:00 AM

Document Has Been Signed on 11/03/2022 11:21 AM - 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 ELDERLY IIFACILITY NUMBER:
198602876
ADMINISTRATOR:SINCLAIR, REBECCAFACILITY TYPE:
740
ADDRESS:2408 SAN JACINTO COURTTELEPHONE:
(626) 253-5806
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 6DATE:
11/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Nenita Capistrano - Caregiver TIME COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit at the facility during a complaint investigation visit on 11/3/22 to note deficiencies. LPA Flores spoke with Assistant Administrator Michelle Aguirre and explain the reason for the case management.

On 11/3/22 LPA Flores arrived at the facility at 9:10am and conducted a complaint investigation visit. At 10:02am LPA Flores contacted Assistant Administrator over the phone and requested a copy of staff roster, caregiver schedules, and staff files for review. Files were not available at the facility for review at the time of the visit. LPA asked Assistant Administrator Michelle Aguirre over the phone if she would be able to provide the documents for review while LPA is at the facility and conducted the investigation. Assistant Administrator stated to be dealing with an emergency and is unable to provide the documents at the time of the visit to leave an email address and she will email the documents to LPA.

Deficiency is noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted at 11:15am with Nenita Capistrano - Caregiver and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/03/2022 11:21 AM - It Cannot Be Edited


Created By: Mary G Flores On 11/03/2022 at 10:50 AM
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 II
FACILITY NUMBER: 198602876

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2022
Section Cited
CCR
87412(f)

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(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidence by:
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Licensee will ensure files are maintain at the facility or accessible and will provide a copy of staff roster, caregiver schedule for the week of 09/26/22 - 11/3/22, staff training on COVID guidelines for the past 6 months, and any COVID related exemption letters for all staff to the department by POC 11/7/22.
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Based on observation Licensee did not ensure personnel records are available at the facility for licensing agency to review fjor all staff which poses a potential health, safety, or personal rights risk to the persons in care.
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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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022


LIC809 (FAS) - (06/04)
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