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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603749
Report Date: 10/25/2024
Date Signed: 10/25/2024 11:46:33 AM

Document Has Been Signed on 10/25/2024 11:46 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 MATTHEW'S HOME FOR THE ELDERLY IIIFACILITY NUMBER:
198603749
ADMINISTRATOR/
DIRECTOR:		BOISTON, BARBARAFACILITY TYPE:
740
ADDRESS:1654 E RUDDOCK ST.TELEPHONE:
(626) 253-5806
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 6DATE:
10/25/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Terry McGee, applicant
Barbara Boiston, house manager		TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Tao conducted an announced pre-licensing inspection. Applicant is applying for Residential Care for Elderly to serve residents for age 60 and above. The current applicant’s licensee is St. Matthew’s Home of the Elderly. The facility was previously licensed to St Francis Home for the Elderly III -198601667. The LPA met with Terry McGee, applicant/ administrator and Barbara Boiston, house manager. The requested capacity is six (6). Facility has an approved Dementia Care Plan. Hospice waiver is approved for six (6).

Fire clearance:
Fire clearance was granted on 08/15/24 for six (6) non-ambulatory and zero (0) bedridden. Fire clearance and Dementia care plan are in place. Auditory device is installed at all exits and operable. Bedroom#1 and #3 are approved for one (1) non- ambulatory in each room. Bedroom #2 and #4 are approved for two (2) non- ambulatory in each room. Garage in not approved for residents or staff residence.

Structure:
The property is a single-family residence located in a neighborhood, consisting of four (4) bedrooms, two (2) full bathrooms, one (1) half bathroom, kitchen, dining room, living room with TV, laundry room, family room, and detached garage. Passageways, walkways and patios are free from obstructions. The entrance and side areas are free of hazards and debris. Garage is not accessible to residents.

(- Continued on LIC 809 C -)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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 4
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 MATTHEW'S HOME FOR THE ELDERLY III
FACILITY NUMBER: 198603749
VISIT DATE: 10/25/2024
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Bedrooms and Bathrooms for Residents:
Bedrooms have nightstand, adequate lighting, adequate closet and drawer space. Bedrooms are spacious and allow for easy passage between and comfortable for usage. Toilet, wash basin, bathtub/shower in bathrooms are operable. Bedrooms are accommodated for residents. Grab bars are maintained for each toilet, bathtub and shower.

Linens & Hygiene Supplies:
Sufficient linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are available. Adequate supply of linen, wash clothes and towels are observed.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Dishwasher in kitchen properly installed and functioning. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet in the kitchen and inaccessible to residents. Food supply consist of two days of perishable and two weeks of non-perishable was observed.

Medications, First-Aid Kit & Book:
Medication cabinet is installed with a lock and inaccessible to residents. First aid kit has a thermometer, tweezers, scissors, antiseptic, bandages, and gauze. First Aid manual from American red cross was available for staff use and inaccessible to residents.

Smoke Detectors:
Dual Smoke /carbon monoxide detectors are tested and operable. They are located in hallways and each bedroom.

(-Continued on LIC 809 C -)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 MATTHEW'S HOME FOR THE ELDERLY III
FACILITY NUMBER: 198603749
VISIT DATE: 10/25/2024
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Appliances:
Stove burners, oven, microwave, washer, and dryer working. There are two refrigerators, located in the kitchen and garage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The residence is equipped with central air and heat.

Toxins:
Poisons, toxins, and cleaning supplies are locked and inaccessible to residents. They are stored separately from food source.

Emergency Phone Numbers, Exit Plan, Signages and posters:
Emergency Disaster Plan and Labor law poster are posted. Exit Plan are available for review.

Outdoor activity area in backyard:
Outdoor activity area is furnished with chairs and table and in compliance. Shaded area in the backyard at the outdoor activity area is provided.

Residents & Staff Files:
Locked cabinets for records of staff and residents are installed and available. Residents file are observed. Applicant will not handle cash resources for residents.

Water Temperature:
Tested at 111.6 degrees Fahrenheit.

Menu and phone:
Menus are available for review. Free landline telephone is available for residents’ use and operable.

(- Continued LIC 809 C -)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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 MATTHEW'S HOME FOR THE ELDERLY III
FACILITY NUMBER: 198603749
VISIT DATE: 10/25/2024
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Fire extinguishers:
Fire extinguishers are available in the facility. They are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has recreational materials for the residents’ use and commensurate with the plan of operation.

Pool:
No bodies of water located at the facility.

Finding:
No issue was observed during today’s visit.

Exit:
Exit conference was conducted. Component III orientation was conducted during this visit.

A copy of this report was provided to applicant. 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, s/he has been instructed to communicate with the CAB Analyst who assigned to his/her application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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