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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004368
Report Date: 03/21/2025
Date Signed: 03/21/2025 02:52:57 PM

Document Has Been Signed on 03/21/2025 02:52 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MATSONIA LANE HOMESFACILITY NUMBER:
306004368
ADMINISTRATOR/
DIRECTOR:		MYLENE GABATFACILITY TYPE:
740
ADDRESS:19691 MATSONIA LANETELEPHONE:
(714) 965-2710
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 2DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Adelina Vereracion
Maricar Juliano		TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA Haley was greeted and granted entry by staff who contacted Licensee/Administrator (AD) Maylene Gabat who was unable to attend the visit. AD Maylene has a current Administrators certificate that expires November 19, 2026.

Matsonia Lane Homes is a one-story community with five bedrooms and two bathrooms.
The current capacity is 3 and the census was 2 during the visit.

During the inspection, LPA Haley observed all resident bedrooms. The bedrooms had all the requirements and were in compliance with regulation guidelines. In the hallway near the main bathroom, LPA Haley observed incontinent care supplies. A Carbon monoxide detector was observed in the hallway and tested operational. In a hallway closet right cross from the kitchen there is a closet with a nonperishable food supply.

Resident bathrooms were observed. Hot water temperatures were measured in between 111.2 degrees Fahrenheit and 111.5 degrees Fahrenheit. No hazardous items were observed in the resident bathrooms.

In the kitchen LPA observed a perishable food supply in compliance with regulation requirements. Knives and sharp objects are kept locked in a drawer near the sink. No hazardous cleaning chemicals are stored in the garage. The stove was being used to prepare lunch for the residents and two of the burners were in good working order. However, after staff finished cooking and the other two burners were checked, the top left burner was observed to be non-operational.

A first aid kit with all the required elements was observed in a drawer in the dining room. The fire extinguisher was fully charged and mounted on the wall in the kitchen/dining room next to the refrigerator. Resident files are kept in a locked file cabinet in the dining room. In the same locked cabinet are emergency bags for each resident, an emergency water supply, and resident medications.

Continued on LIC809C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MATSONIA LANE HOMES
FACILITY NUMBER: 306004368
VISIT DATE: 03/21/2025
NARRATIVE
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In the garage, LPA Haley observed a laundry area with a washer and dryer, a locked cabinet with all the hazardous cleaning chemicals, an office area, and filing cabinets with staff files and other facility files. There’s an additional refrigerator with an additional food supply and refrigerated medication for one of the residents.

The backyard was clean and organized. No tripping hazards were observed. There is a swimming pool in the backyard surrounded by a self-latching gate that measured 5 feet off the ground at the entrance of the gate.

Smoke detectors were observed in all resident rooms and the hallway, all of which tested operational. Emergency drills have not been conducted. 2 staff files, 2 resident files, and 3 resident medications were reviewed during the inspection.

Deficiencies are being cited as a result of today’s visit.

An exit interview conducted and a copy of this report, and appeal rights was provided to staff.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/21/2025 02:52 PM - It Cannot Be Edited


Created By: Jerome Haley On 03/21/2025 at 02:12 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MATSONIA LANE HOMES
FACILITY NUMBER: 306004368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being or residents and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview confirmation from staff, the licensee did not comply with the section cited above in which poses a potential health and safety risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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The stove will be repaired or replaced by the POC due date. The licensee/Administrator will email LPA Haley a video of all the burners on the stove being light unassisted. Photos are not acceptable.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/21/2025 02:52 PM - It Cannot Be Edited


Created By: Jerome Haley On 03/21/2025 at 02:18 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MATSONIA LANE HOMES
FACILITY NUMBER: 306004368

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above which poses an immediate health, safety and personal rights risk to persons in care. Individual 1 (ID1) was observed in the facility as a trainee. ID 1 said their first day was Thursday, March 20, 2025.
POC Due Date: 03/21/2025
Plan of Correction
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The individual was asked to leave the facility and is not allowed back inside the facility until being fingerprint cleared and properly associated to the facility roster.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, which poses an immediate health and safety risk to persons in care. One of the staff members present during the inspection confirmed there has been no recent emergency evacuations.
POC Due Date: 03/24/2025
Plan of Correction
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The facility will complete an emergency evacuation drill by the close of business Monday, March 24, 2025 for all staff on each shift. The Licensee/Administrator will email LPA Haley the sign in sheet that shows the date, time, type of emergency, and all participants (residents and staff).
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2025


LIC809 (FAS) - (06/04)
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