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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220979
Report Date: 12/17/2024
Date Signed: 12/17/2024 01:42:55 PM

Document Has Been Signed on 12/17/2024 01:42 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/
DIRECTOR:		MATEO, ROGELIO D.FACILITY TYPE:
735
ADDRESS:18700 LEMAY STREETTELEPHONE:
(818) 514-6807
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 3DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Carolina Mateo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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At 10:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with the Administrator, Carolina Mateo, and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out and observed the following:

Kitchen: At approximately, 10:55 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 11:00 AM a fully charged fire extinguisher was observed near the kitchen. It was last inspected on 04/30/2024.

Medications: At approximately, 11:05 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 in the hallway and LPA observed extra linens. 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. 11:30 AM, hot water temperature measured at 119.8°F.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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: 12/17/2024
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Common Areas: At 11:35 AM, the facility maintains a comfortable temperature at 71°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 11:45 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, 11:55 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 next to the washer and dryer outside.

Between 12:00 PM to 1:15 PM, LPA reviewed records of three (3) clients and two (2) 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: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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