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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221933
Report Date: 10/07/2024
Date Signed: 10/07/2024 12:07:25 PM

Document Has Been Signed on 10/07/2024 12:07 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/
DIRECTOR:		MATEO, CAROLINA & ROGELIOFACILITY TYPE:
735
ADDRESS:6861 TAMPA AVE.TELEPHONE:
(818) 776-8716
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 3DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Carolina Mateo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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At 9:45 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 the Administrator toured the facility inside and out.

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 clients.

Medications: At approximately, 10:05 AM, LPA observed medications are centrally stored and locked next to the kitchen in a separate cabinet.

Kitchen: At 10:07 AM, LPA 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 10:15 AM, LPA toured the bedrooms and observed that there are six (6) bedrooms. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #3 (three) is for live-in staff that is located by the entrance of the facility. Bedroom # six (6) is used for staff bedroom as well that is located by the common area.

Bathrooms: At approximately 10:20 AM, LPA observed two (2) bathrooms in the facility. 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. LPA measured the water temperature in the shared bathroom to be 106.5 degrees Fahrenheit.

Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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 GUEST HOME
FACILITY NUMBER: 191221933
VISIT DATE: 10/07/2024
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Common Areas: The facility maintains a comfortable temperature at 79°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. LPA observed a fully charged fire extinguisher in the living room last serviced on 04/29/2024.

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 10:30 AM, 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, 10:35 AM, LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. The back yard was maintained and had gardened areas with fruit trees. No swimming pool or bodies of water at the facility.



Between 11:00 AM to to 12:15 PM, LPA reviewed records of three (3) clients and one (1) staff. Client and staff records appeared to be complete and updated.

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

No citation issued 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: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC809 (FAS) - (06/04)
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