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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221933
Report Date: 11/28/2023
Date Signed: 11/28/2023 03:14:08 PM

Document Has Been Signed on 11/28/2023 03:14 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 GUEST HOMEFACILITY NUMBER:
191221933
ADMINISTRATOR:MATEO, CAROLINA & ROGELIOFACILITY TYPE:
735
ADDRESS:6861 TAMPA AVE.TELEPHONE:
(818) 776-8716
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jill Marie Mateo, Assistant AdministratorTIME COMPLETED:
03:25 PM
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At 11:00am on 1128/2023, Licensing Program Analysts (LPAs) Huma Rahimi, and Leslie Ngo-Castaneda conducted an unannounced annual visit. LPAs met with staff Miriam Mendoza and was advised the reason for the visit. LPAs advised staff to please contact administrator, Jill Mateo arrived at 11:50 and was disclosed the reason for the visit. LPAs and assistant administrator began to tour the facility at 11:55am.

The facility is a single story building with six(6) bedrooms, two (2) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for four (4) ambulatory residents.

Medications: At approximately, 11:30 am LPAs observed medications are centrally stored and locked next to the kitchen in a separate cabinet.

Kitchen: At 11:58 am LPAs observed an adequate supply of perishable and non-perishable food in the kitchen. The facility has two (2) refrigerators. 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.

Bedrooms: At 12:05 pm LPAs toured the bedrooms and observed that there are six (6) bedrooms. Room #1 is a private room that is located in the hallway and room #4 is for private use that is located by the dining room area. Room #2 is shared that is located at the end of the hallway. Bedroom #3 (three) is for live-in staff that is located by the entrance of the facility. Room # five (5) is used as an office and room # six (6) is used for staff bedroom as well that is located by the common area. The assistant administrator noted that the staff rooms and office are always locked. All bedrooms contained a chair, night-stand, lamp, flashlight, storage, and bed with adequate bedding. The facility walls, floors, ceilings, windows, screens, and curtains were clean and in good repair.

Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MATEO'S GUEST HOME
FACILITY NUMBER: 191221933
VISIT DATE: 11/28/2023
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Bathrooms: At approximately 12:20 pm, LPAs observed two (2) bathrooms in the facility. Bathrooms #1 is located in the hallway in between room #1 and room #2. Bathroom #2 is located inside bedroom #6 inside staff bedroom. All bathrooms contained liquid soap, paper towels, hand washing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. LPAs measured the water temperature in the shared bathroom to be 105 degrees Fahrenheit.

Common Areas: The facility maintains a comfortable temperature at 72°F. The living room and dining area appeared clean and were properly furnished. The living room has a television and comfortable furniture. No obstructions and or tripping hazards throughout the facility. Exit doors were unlocked, and all emergency exit paths were free from obstructions.

Laundry Room: 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.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 12:45 pm they were tested and observed to be operational. Carbon monoxide was located in a hallway was also tested and observed to be operational.

Outside areas: At approximately, 12 55 pm, LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. The back yard was maintained and had gardened areas with fruit trees.



Between 12:00 pm to 2:30 pm, LPAs reviewed records of four (4) clients and three (3) staff. Client and staff records appeared to be complete and updated. LPAs observed that one (1) staff was not associated with the facility based on the guardian and LIS search; and therefore, a civil penalty is issued.

Administrative: LPA collected Certificate of Liability Insurance, and LIC.500.

An exit interview was conducted citation was issued (refer to 809D) and Civil Penalty assessed (refer to LIC 421BG), appeals rights discussed and provided, and a copy of this report was given to the Assistant Administrator.

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

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
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Document Has Been Signed on 11/28/2023 03:14 PM - It Cannot Be Edited


Created By: Huma Rahimi On 11/28/2023 at 02:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MATEO'S GUEST HOME
FACILITY NUMBER: 191221933

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Iinterview and record review, the licensee did not comply with the section cited above in one (1) of four (4) staff members not being associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Licensee agreed to associate staff through Guardian or send LIC 9082, LIC 508 with a copy of individuals drivers license/state issued identification to Regional Office. Licensee will send a screenshot copy of completed association to LPA Huma by POC Date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


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