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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602197
Report Date: 05/06/2022
Date Signed: 05/06/2022 10:19:13 AM

Document Has Been Signed on 05/06/2022 10:19 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST MATTHEWS HOME FOR THE ELDERLYFACILITY NUMBER:
198602197
ADMINISTRATOR:CASTRO, SILVIAFACILITY TYPE:
740
ADDRESS:1004 NASHPORT DRIVETELEPHONE:
(909) 392-2266
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 6CENSUS: 6DATE:
05/06/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff / Reinalyn Martin
Administrator / Silvia Castro
TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Plan Of Correction (POC) visit to follow up on the deficiency issued during the 4/28/22 case management visit. Upon arriving at the facility, LPA met with Staff / Reinalyn Martin and was later joined by the Administrator / Silvia Castro who assisted with the visit. The purpose of this visit was explained.

On 4/28/22 the facility was cited for:

Personnel Requirements - General. Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:


During a complaint investigation conducted on 4/28/22, LPA discovered that individuals: Reinalyn Martin and Reginald Zaragosa have been working at the facility prior to requesting a transfer of a criminal record clearance.

The Plan of Correction (POC) for this deficiency stated that the Administrator will ensure individuals: Reinalyn Martin and Reginald Zaragosa are associated to St Matthews Home for the Elderly and provide proof to CCL by the POC due date of 4/29/22.

The Administrator failed to submit the POC to CCL by the POC due date of 4/29/22, therefore Civil Penalties are being issued for period 4/30/22 - 5/6/22. Total of 7 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $700. Civil penalties will continue to accrue until the POC is submitted to CCL.

A deficiency is cited per California code of Regulations, Title 22, Division 6
LPA explained the citation, civil penalty assessment, and appeal rights.
Exit interview was conducted and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2022
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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