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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220979
Report Date: 01/25/2022
Date Signed: 01/25/2022 02:26:31 PM

Document Has Been Signed on 01/25/2022 02:26 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MATEO'S HOME CAREFACILITY NUMBER:
191220979
ADMINISTRATOR:MATEO, ROGELIO D.FACILITY TYPE:
735
ADDRESS:18700 LEMAY STREETTELEPHONE:
(818) 514-6807
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
01/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:Gaspara GzamenTIME COMPLETED:
02:27 PM
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At approximately 1:25 PM on 01/25/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit and met with staff. LPA disclosed the reason for the visit.

Census: 4

Staff debriefed LPA that Regional Center Quality Assurance conducted an inspection earlier in the day.

Entry: LPA observed a clean outdoor area. The visitor policy sign was removed at the request of Regional Center.

Screening: Staff took LPA’s temperature at the front door. Staff requested LPA record temperature, any symptoms, time of visit, and name. LPA noticed an additional log for all consumer and staff temperatures and symptom checks.

At approximately 1:35 PM, LPA conducted the physical plant tour.

Bedrooms: The facility contained 5 bedrooms. 1 bedroom is a shared bedroom, and 4 are private bedrooms. 2 out of the 4 private bedrooms, Bedroom #4 and Bedroom #3, are staff rooms. Both staff bedrooms were locked. Bedroom #5 is a shared bedroom with beds at least 6 feet apart. All bedrooms were clean and tidy. In Bedroom #2, LPA observed a staff from an outside agency working with a consumer. The staff was background check cleared and fully vaccinated.

Bathrooms: The facility has 2 bathrooms. Both bathrooms contained fully stocked paper towels, liquid soap, trash cans with revolving lids, and handwashing signs with instructions.

Common Areas: The living room was in good repair and all furniture was in good condition. LPA observed signs related to COVID-19 policies such as Cough Etiquette, Signs and Symptoms of COVID-19, cleaning instructions, and Droplet Precautions.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MATEO'S HOME CARE
FACILITY NUMBER: 191220979
VISIT DATE: 01/25/2022
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*** This report has been amended to include the that LPA conducted exit interview and issued the report***

Kitchen: The kitchen was in good order. LPA suggested a handwashing sign by the sink.

Laundry: The facility contains a washing machine and dryer in good working order.

All consumers have access to a free house telephone.

Isolation: LPA asked staff about the occurrence of a COVID positive consumer. Staff noted they are trained in donning and doffing PPE, and they are able to provide meals and medications to residents in isolation. Staff are also able to sanitize isolation rooms and sanitize laundry machines after each load.

Exit interview conducted and report issued.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
LIC809 (FAS) - (06/04)
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