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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191221933
Report Date: 12/08/2025
Date Signed: 12/08/2025 04:22:04 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
12/03/2025 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20251203153637
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:
12/08/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Therese Gajete, Administrator DesigneeTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff did not administer resident's medications as prescribed.
INVESTIGATION FINDINGS:
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At 9:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannouced initial complaint visit to investigate the above stated allegation. LPA met with the Staff #1 (S1) Elaine Ponferrada and the Administrator Designee was contacted via telephone. LPA explained the reason for the visit. The Designee arrived at 10:30 AM to the facility.

During course of the investigation, interviews and record review were made. At 9:55, LPA requested client and staff roster. At 10:05 AM, LPA requested copies of pertinent information which include, but not limited to Physician Report, Admission Agreement, Appraisal Needs and Services Plan and ect., relevant to the course of investigation. At approximately 10:15 AM, LPA conducted a physical plant tour. Between 10:20 AM to 3:15 PM, LPA conducted an interview with the Administrator Designee, Staff #1 (S1), and three (3) out of four (4) clients who were able to communicate.

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

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
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 3
Control Number 31-AS-20251203153637
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: 12/08/2025
NARRATIVE
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Staff did not administer resident's medications as prescribed.
It was reported that on 12/02/2025, facility staff did not provide medication to Client #1 (C1). To investigate this allegation, LPA conducted interviews with the facility Designee and Staff #1 (S1), interviewed clients, and reviewed C1’s medication records. The Designee stated they were not aware of any incidents related to the allegation. During the interview, S1 reported that C1 has two (2) prescribed medications:
  • Vitamin D3, 50 mcg, to be taken once daily with food, and
  • Loperamide 2 mg, to be taken as needed (PRN).

S1 further stated that on 12/02/2025, they attempted twice to administer C1’s Vitamin D3 by knocking on C1’s bedroom door, but C1 did not open the door or respond to either attempt. S1 also reported that C1 had been refusing to take Vitamin D3 from 11/29/2025 through 12/07/2025. LPA reviewed C1’s Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR). Record review confirmed that C1 is prescribed two medications and showed missing doses of Vitamin D3 from 11/29/2025 through 12/07/2025.

LPA also interviewed three (3) out of four (4) clients who were able to communicate. Two (2) of the three (3) clients stated they never missed their prescribed medications. One (1) client stated they did miss their prescribed medication and reported they were never offered medication by knocking on their door. This client also reported that they frequently remind staff about their medication and never refused to take their prescribed medication. Based on staff interviews, client interviews, and record review, there is sufficient evidence to support that staff did not administer medications as prescribed for C1. Therefore, the allegation is determined to be Substantiated.

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

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20251203153637
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: 12/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2025
Section Cited
CCR
80075(b)(5)
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80075 Health Related Services(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5)If the client's physician has stated in writing....:
This requirement is not met as evidenced by:
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The Licensee/Administrator will retrain all staff on medication administration procedures, including proper documentation of medication refusals, missed doses, and follow-up actions required when a client does not respond to medication attempts.
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Based on interviews and record review, the licensee failed to ensure that Client #1 (C1) received prescribed medication as ordered by the physician. This poses a potential health and safety risk to clients in care.
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Proof of staff training (sign-in sheet and training material) will be submitted to LPA by: 12/15/25.
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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: 12/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
LIC9099 (FAS) - (06/04)
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