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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603748
Report Date: 08/28/2025
Date Signed: 08/28/2025 11:47:17 AM

Document Has Been Signed on 08/28/2025 11:47 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST MATTHEW'S HOME FOR THE ELDERLY VFACILITY NUMBER:
198603748
ADMINISTRATOR/
DIRECTOR:		MCGEE, TERRYFACILITY TYPE:
740
ADDRESS:1044 CLARADAY STTELEPHONE:
(626) 222-2664
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 0DATE:
08/28/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Terry McGee, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Blanca Gonzalez and Mary Flores conducted an announced Pre-Licensing Inspection visit and met with Applicant Terry McGee and Barbara Boiston, House Manager.

The facility has an approved fire clearance to be licensed to serve six (6) non-ambulatory residents ages 60 and above.

LPAs and applicant toured the physical plant interior and exterior. The Pre-Licensing Inspection CARE Tool was used. The following was observed/inspected:

The facility is a single-story home located in a residential area of Glendora consisting of a living room, dining area, kitchen, three (3) bedrooms, two (2) bathrooms. The home is located behind a current licensed facility in the same property. They will not be sharing staff or food preparation as each will prepare their own meals. Laundry area observed in the hallway included a cabinet for extra towels and linens. Fire smoke alarms and carbon monoxide detectors observed, tested and are operable. The fire extinguishers observed and charged.

Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. Sharps were observed secured in a locked kitchen cabinet, inaccessible to residents.
(CONTINUED ON LIC 809C)
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ST MATTHEW'S HOME FOR THE ELDERLY V
FACILITY NUMBER: 198603748
VISIT DATE: 08/28/2025
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Medication will be centrally located in a locked kitchen cabinet, inaccessible to residents in care.Staff and client files will be maintained locked in a cabinet located in the kitchen.
Dining area was clean with sufficient seating for six (6) residents. Living room was observed with sufficient seating for six (6) residents. Applicant will ensure that there is a comfortable moving/walking area in between the dining area and the living area.
Grab bars and non-skid mats were observed in bathrooms. The water temperature was tested between 114.5 and 118.5 in both bathrooms and it is within the required 105-120 degrees F.
Residents’ bedrooms have all require furniture which includes, for each resident, a chair, nightstand, a lamp, or lights sufficient for reading. Bed linens were clean and in good repair. There is a closet space for clothing and other belongings
All cleaning solutions and disinfectants were observed locked under the kitchen sink and kitchen cabinet.

Doors, exits, hallways, and passageways were clear and free of obstruction. The front and back yards were observed to be clean and free of debris. There is an outdoor seating area with an umbrella for shade and sufficient seating residents. No pools or bodies of water were observed in or around the home. There are no firearms present at the facility. The first-aid kit has required items, and a current manual was observed and is kept in the kitchen.

The Pre-licensing is completed. Applicant will send pictures of required posters posted as they were available but not posted and an additional grab bar in bathroom #2 as there was one grab bar in the shower and there was not one on the side of the shower. Once that is completed the physical plant meets Title 22 Regulations.

Comp III was not conducted as the Applicant being is a licensee and has other facilities.

Exit interview was conducted with applicant Terry McGee and a copy of this report was provided to Applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
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