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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221933
Report Date: 10/20/2025
Date Signed: 10/20/2025 02:16:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/29/2025 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20250829104646
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:
10/20/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jill Mateo, Administrator DesigneeTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff speaking about client(s) inappropriately.
INVESTIGATION FINDINGS:
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At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit to investigate the above stated allegations. LPA met with the Staff #1 (S1) Elaine Ponferrada and the Administrator was contacted via telephone. LPA explained the reason for the visit. The Administrator was unable to come to the facility and the Administrator Designee arrived at 11:45 AM to receive and sign today's report.

An initial complaint visit was conducted on 09/03/2025. LPA obtained copies of the client and staff roster and other pertinent information, including but not limited to Centerally Stored Medication Record (CSMR), Physician Report, Admission Agreement, Appraisal Needs and Services Plan, etc. Interviews were conducted with the Administrator, one (1) staff, and two (2) out of four (4) clients who were avaliable. During today's visit LPA conducted an interview with an additional one (1) out of four (4) clients.

Continue on LIC 9099C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/29/2025 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20250829104646

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:
10/20/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elaine Ponferrada, StaffTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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9
Staff mismanaged clients medication.
INVESTIGATION FINDINGS:
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At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit to investigate the above stated allegations. LPA met with the Staff #1 (S1) Elaine Ponferrada and the Administrator was contacted via telephone. LPA explained the reason for the visit. The Administrator was unable to come to the facility and the Administrator Designee arrived at 11:45 AM to receive and sign today's report.

An initial complaint visit was conducted on 09/03/2025. LPA obtained copies of the client and staff roster and other pertinent information, including but not limited to Centerally Stored Medication Record (CSMR), Physician Report, Admission Agreement, Appraisal Needs and Services Plan, etc. Interviews were conducted with the Administrator, one (1) staff, and two (2) out of four (4) clients who were avaliable.

Continue on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20250829104646
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/20/2025
NARRATIVE
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Staff mismanaged clients medication.
It was alleged that Staff #1 (S1) provided the wrong medication to Client #1 (C1). To investigate this allegation, LPA conducted interviews with the Administrator, staff, and three (3) out of four (4) clients, and reviewed C1’s Centrally Stored Medication Record (CSMR) and related documentation. Interviews with staff and the Administrator revealed that all medications were administered in accordance with physician orders and the facility’s medication policies. LPA was informed that C1 frequently refused to take the prescribed Vitamin D3 (50 mcg), and S1 documented each refusal appropriately. Interviews with clients indicated that on 02/23/2025, C1 was transported to the hospital due to a general allergic reaction after taking Sumatriptan (25 mg). It was initially believed that the medication had been administered in error. However, review of the CSMR and physician’s orders confirmed that Sumatriptan (25 mg) was indeed prescribed to C1 by the treating physician. The medication was subsequently discontinued on 02/23/2025, following C1’s hospital discharge and physician’s direction.

Based on interviews and record review, there is insufficient evidence to conclude that S1 provided the wrong medication to C1. Although the incident occurred as described, the evidence obtained does not support that staff administered medication contrary to physician orders. Therefore, the allegation that S1 provided wrong medication to C1 is UNSUBSTANTIATED.




Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20250829104646
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/20/2025
NARRATIVE
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Staff speaking about client(s) inappropriately.
It was alleged that Staff #1 (S1) made inappropriate and unprofessional comments about Client #1 (C1) in the presence of other clients. To investigate this allegation, LPA conducted interviews with the Administrator, S1, and three (3) of the four (4) clients.

Interviews revealed that on 08/22/2025, one (1) of four (4) clients complained about mosquitoes in the facility, and S1 responded by suggesting the client should “take a shower because you stink.” Further interviews revealed that S1 made a racially insensitive comment when discussing one client’s preference for African American men. During the interview, the Administrator acknowledged that S1 used the racial term, stating that S1 was unaware it was offensive at the time. The Administrator corrected S1, explaining that the term was inappropriate, after which S1 apologized and agreed not to use the term again.

Based on the preponderance of evidence obtained through interviews and documentation review, it was determined that S1 engaged in unprofessional and inappropriate communication toward clients, including the use of an offensive racial term and comments that disrespected clients’ personal rights.

Therefore, the allegation that S1 spoke inappropriately about clients is SUBSTANTIATED.


A deficiency issued and appeal rights explained and given.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250829104646
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2025
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Personal Rights (a)...each client shall have personal rights which include,...(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by:
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S1 will complete training on professional communication and client rights. Training proof will be submitted to LPA by POC due date.
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Based on interviews the licensee did not comply with the section cited above by staff speaking inappropriately to C1 using racial term & disrespected C1 which poses a potential Health, Safety, or Personal Rights risk to clients in care.
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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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5