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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221933
Report Date: 05/06/2025
Date Signed: 05/06/2025 11:50:17 AM

Document Has Been Signed on 05/06/2025 11:50 AM - 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: 4DATE:
05/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Carolina MateoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 05/06/25 Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Carolina Mateo for a case management visit. The purpose of the case management visit is to address deficiencies observed during the course of investigation for complaint # 31-AS-20250411092910. The deficiencies were not alleged but are related to the complaint.

LPA Casillas was investigating the above referenced complaint when LPA observed that Staff #1 (S1) had a “Pending” status on their fingerprint clearance. S1 has been providing direct care and supervision to clients since 08/22/24 without being fingerprint cleared to work in the facility. LPA explained to Administrator that this is an immediate civil penalty, and that staff needs to be removed and not provide care and supervision until properly being fingerprint cleared. Administrator states that S1 works as needed but that they would be removed from the schedule immediately.

LPA also observed during staff file review that Staff #2 (S2) did not have a health clearance to include tuberculosis (TB) testing prior to 03/20/25. LPA observed that S2 was hired on 01/20/25 but had not completed a health clearance nor had S2 provided a TB test within the first seven (7) days of being hired or a valid test performed not more than one year prior. LPA explained to Administrator that all staff need to have a health screening and a valid TB test in order to provide direct care and supervision to clients. Administrator stated that S2 is no longer employed with the facility since S1 resigned on 03/31/25. LPA informed Administrator that even though S2 was no longer employed, S2 provided care and supervision to clients during S2’s tenure at the facility, therefore a citation would be issued. Please see LIC809-D and LIC421-BG

Citations issued. Appeals rights discussed and provided. Exit interview conducted and a copy of this report given to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/06/2025 11:50 AM - It Cannot Be Edited


Created By: Lorena Casillas On 05/06/2025 at 11:05 AM
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: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/07/2025
Section Cited
CCR
80019(e)(2)

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Criminal Record Clearance (e)All individuals subject to a criminal record review pursuant to …shall prior to working... in a licensed facility: (2)Obtain a California clearance or a criminal record exemption...This requirement is not met as evidenced by:
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Administrator informed S1 that they will not be allowed to return until criminal record clearance is obtained. S1 left the facility agreeing not to return until cleared to do so.
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Based on observation and record review S1 has worked at the facility providing direct care to clients since 08/22/24 without a fully processed criminal record clearance. This poses an immediate risk to the health and safety of clients in care.
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A civil penalty for $500 was issued.
Type B
05/16/2025
Section Cited
CCR80065(g)(1)

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Personnel Requirements (g)All personnel…(1)...good physical health shall be verified by a health screening, including a test for tuberculosis…not more than one year prior to or seven days after employment..This requirement is not met as evidenced by:
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POC cleared at time of visit by providing a health screening report to include a tuberculosis test dated 03/20/25.
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Based on file reviews, interviews and observations S2 did not have a health screening including a test for tuberculosis seven (7) days after employment. This poses a potential health and safety 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Lorena Casillas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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