191220979-1-10-2023-31-AS-NRED-CMXTRU-20230110135806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191220979
Report Date: 01/10/2023
Date Signed: 01/10/2023 01:58:20 PM

Document Has Been Signed on 01/10/2023 01:58 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 CARE		FACILITY NUMBER:	191220979
ADMINISTRATOR:	MATEO, ROGELIO D.		FACILITY TYPE:	735
ADDRESS:	18700 LEMAY STREET		TELEPHONE:	(818) 514-6807
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 4		CENSUS: 3	DATE:	01/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Gaspara Gazman		TIME COMPLETED:	02:08 PM

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At 1:00 p.m. on 01/10/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the house manager and disclosed the reason for the visit. LPA and manager toured the facility inside and out.

The facility was last visited on 01/25/2022 for an annual visit. It is a single story building with 5 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 4 ambulatory residents.

At the main entrance, LPA observed signs for the facility’s COVID policies. Additional postings included emergency contacts, confidential complaint contacts, personal rights, emergency disaster plan, facility sketch, and grievance procedure. LPA was screened for infectious disease upon entry. The screening station contained a digital thermometer, temperature log, masks, gloves, hand sanitizer, and N95 masks.

LPA observed an adequate supply of perishable and non-perishable food in the kitchen. A menu was posted on the refrigerator. The stove hood was clean, and all surfaces were sanitary. Sharps were locked above the counter top. Cleaning solutions were locked below the sink. Medications were locked in a high kitchen cabinet. Staff were observed helping a client with food preparation. At 1:12 p.m. a fully charged fire extinguisher was observed near the kitchen. It was last inspected on 05/18/2022. A laundry area was located just outside of the kitchen. The washer and dryer were operational. Detergents were locked in a cabinet.

The facility had 5 private bedrooms. Bedroom #1, #2, and #5 were designated for clients. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #3 and Bedroom #4 were locked and designated for staff. A small office area near Bedroom #4 contained secure consumer files. 3 linen closets, located between Bedroom #1 and Bedroom #2, contained an adequate supply of fresh linens and towels. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 1:21 p.m. LPA measured the room temperature to be 70 degrees Fahrenheit.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

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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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: 01/10/2023

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The facility had 2 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 1:19 p.m. LPA measured the water temperature in the bathroom near the kitchen to be 113.2 degrees Fahrenheit. All emergency exit paths were free from obstructions. Exit gates were unlocked with inward facing latches. At 1:23 p.m. LPA tested the smoke detector to be operational. At 1:25 p.m. LPA tested the carbon monoxide detector to be operational. The front and back yard were maintained. Fruit trees and vines were observed in the back yard. The house phone was located near the screening station. Family was observed visiting with a consumer.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC809 (FAS) - (06/04)

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