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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220979
Report Date: 01/26/2024
Date Signed: 01/26/2024 01:12:12 PM

Document Has Been Signed on 01/26/2024 01:12 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
WOODLAND HILLS S.RO, 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: 3DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Carolina Mateo, AdministratorTIME COMPLETED:
01:40 PM
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At 10:10 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with the house manager Gaspara Gazmen and disclosed the reason for the visit. LPA and manager toured the facility inside and out. The Administrator, Carolina Mateo, arrived at 11:10 AM.

Kitchen: At approximately, 10:25 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. A menu was posted on the refrigerator. The stove hood was clean, and all surfaces were sanitary. Sharps were locked above the countertop. Cleaning solutions were locked below the sink. Medications were locked in a high kitchen cabinet. At 10:30 AM a fully charged fire extinguisher was observed near the kitchen. It was last inspected on 05/26/2023.

Medications: At approximately, 10:25 AM, during the kitchen tour, LPA observed medications are centrally stored and were locked in a high kitchen cabinet.

Bedrooms: The facility is fire cleared for five (5) ambulatory residents. LPA observed total of three (3) bedrooms designated for clients use. Bedroom # one (1) and bedroom # two (2) are for private use. Bedroom # five (5) is shared. Bedroom # three (3) and Bedroom # four (4) were locked and designated for staff. A small office area near Bedroom # four (4) contained secure consumer files. Three linen closets, located between Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. All bedrooms for client use are properly furnished, clean and have appropriate bedding and linens.

Bathrooms: LPA observed two (2) bathrooms and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 10:39 AM, hot water temperature measured at 115.2°F.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MATEO'S HOME CARE
FACILITY NUMBER: 191220979
VISIT DATE: 01/26/2024
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Common Areas: At 10:40 AM, the facility maintains a comfortable temperature at 70°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The garage is always locked and is used as a storage LPA also observed a vehicle parked in the garage.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10:47 AM they were tested and observed to be operational. Carbon monoxide was located in a hallway and was also tested and observed to be operational.

Outside areas: At approximately, 10:50 AM LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. A laundry area was located just outside of the kitchen. The washer and dryer were operational. Detergents were locked in a cabinet.

Between 11:00 AM to 12:30 PM, LPA reviewed records of four (4) clients and three (3) staff. Client and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC809 (FAS) - (06/04)
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