191221933-10-5-2022-31-AS-NRED-CJWV6Z-20221005161023

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191221933
Report Date: 10/05/2022
Date Signed: 10/05/2022 04:10:37 PM

Document Has Been Signed on 10/05/2022 04:10 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 GUEST HOME		FACILITY NUMBER:	191221933
ADMINISTRATOR:	MATEO, CAROLINA & ROGELIO		FACILITY TYPE:	735
ADDRESS:	6861 TAMPA AVE.		TELEPHONE:	(818) 776-8716
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 4		CENSUS: 4	DATE:	10/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:10 PM
MET WITH:	Carolina Mateo		TIME COMPLETED:	04:20 PM

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At 3:10 p.m. on 10/05/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility was last visited on 07/27/2019 for an annual visit. It is a single story building with 5 bedrooms, 2 bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for 4 ambulatory residents. The facility had a pet dog.

LPA observed a maintained front yard. LPA was screened for infectious disease upon entry. The screening station contained a digital thermometer, surgical masks, N95 masks, hand sanitizer, sanitizing wipes, gloves, and a visitor log. The visitor log tracked symptoms and temperature. Facility postings included the confidential complaint contacts, facility license, neighborhood grievance procedure, personal rights, Emergency Disaster Plan, menu, and activity calendar.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 3:30 p.m. LPA measured the room temperature to be 79 degrees Fahrenheit. A linen closet near the shared bathroom contained an adequate supply of fresh linens. Consumers were watching television and talking on the phone. One consumer joined LPA during the tour.

LPA observed an adequate supply of perishable and non-perishable food in the kitchen. The facility had two refrigerators and one freezer. The stove hood was clean. All appliances and surfaces were sanitary and functional. Sharps were locked above the counter top, and cleaning solutions were locked under the sink. Exit doors were unlocked, and all emergency exit paths were free from obstructions. A laundry area outside had a functioning washer and dryer. Detergents were locked in a standing cabinet. Two sets of patio furniture were located under a shaded awning. The furniture was in good condition. The back yard was maintained and had gardened areas with fruit trees.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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 GUEST HOME	FACILITY NUMBER: 191221933
	VISIT DATE: 10/05/2022

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The facility had 5 bedrooms. All bedrooms were private, and one bedroom was designated for staff. The staff bedroom was free of hazards. All bedrooms contained a chair, nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. 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 3:35 p.m. LPA measured the water temperature in the shared bathroom to be 105.3 degrees Fahrenheit. At 3:40 p.m. LPA tested the dual functioning smoke and carbon monoxide detector to be operational. 3 out of 3 detectors functioned simultaneously when tested, and an additional verbal alert sounded. At 3:41 p.m. LPA observed 2 fully charged fire extinguishers in the living room. They were last inspected 05/18/2022.

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: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC809 (FAS) - (06/04)

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