<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602876
Report Date: 08/22/2023
Date Signed: 08/22/2023 10:41:44 AM

Document Has Been Signed on 08/22/2023 10:41 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
GREATER LA AC/SC, 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:
08/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Nenita Capistrano - Caregiver TIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit during a complaint investigation visit. LPA met with Nenita Capistrano caregiver and explained the reason for the visit.

On 11/3/22 LPA Flores conducted an unannounced complaint investigation visit. During this visit LPA requested Administrator Michelle Aguirre to email the following documents: staff roster, Caregiver schedules for the month of September, October, and November 2022, Trainings or In-services provided during 2022, Visitor’s log for September, October, November 2022, as they were not available for review at the facility. On 1/18/23 LPA Flores followed up regarding documents requested, LPA did not received the documents.

Deficiencies are being cited under Title 22 Regulations on LIC 809D.

Exit interview was conducted with caregiver and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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 08/22/2023 10:41 AM - It Cannot Be Edited


Created By: Mary G Flores On 08/22/2023 at 10:31 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: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2023
Section Cited
CCR
87411(c)(6)

1
2
3
4
5
6
7
87411 Personnel Requirements - General:(c) All RCFE...(6)The licensee shall maintain documentation pertaining to staff training in the personnel records, ... For on-the-job training,..

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will certify on LIC 9098 that files will be available for review at the facility and will submit the requested trainings to the department by POC due date 8/29/23.
8
9
10
11
12
13
14
Based on document review and observation licensee failed to ensure staff #1 and #2 files were available for review during the visit conducted on 11/3/23 and to provide documents after which poses a potenital risk to the health, safety, personal rights of the persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2