198602197-5-19-2026-28-AS-GCAO-DTV59W-20260507194614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602197
Report Date: 05/07/2026
Date Signed: 05/19/2026 11:16:17 AM

Document Has Been Signed on 05/19/2026 11:16 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ST MATTHEWS HOME FOR THE ELDERLY		FACILITY NUMBER:	198602197
ADMINISTRATOR/ DIRECTOR:	CASTRO, SILVIA		FACILITY TYPE:	740
ADDRESS:	1004 NASHPORT DRIVE		TELEPHONE:	(909) 541-5017
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY: 6		CENSUS: 5	DATE:	05/07/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Silvia Castro, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Reinalyn Martin, Caregiver explained the reason for the visit. Silvia Castro, Administrator arrived shortly thereafter.

The facility is licensed to serve residents ages sixty (60) and older. The approved capacity is six (6) non-ambulatory residents and one (1) bedridden only. This facility may retain no more than two (2) hospice residents. There were two (2) residents under hospice care during inspection.

Facility Tour & Observations

Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present.

Physical Plant

The facility is located in a residential area and consists of a one-story home containing four (4) resident bedrooms, three (3) restrooms which one is private restroom, kitchen, dining/living room area, garage/laundry area, front yard, and backyard.

LPA observed four (4) resident bedrooms, all containing the required furnishings including beds, mattresses, linens, dressers, chairs, and adequate lighting. Cleaning supplies and toxic substances were observed locked and inaccessible to residents in the kitchen, garage, and under a bathroom sink. Bathrooms were clean and equipped with required grab bars near showers and toilets, as well as non-skid mats. Hot water measured within the required range of 105°F–120°F. Extra linens and towels were available in a hallway cabinet.

Smoke and carbon monoxide detectors were tested and observed to be functional. Several fire extinguishers were observed throughout the facility. No bodies of water were present on the premises. The backyard provided shaded seating for residents. Passageways and exits were observed to be clear and unobstructed. (continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST MATTHEWS HOME FOR THE ELDERLY	FACILITY NUMBER: 198602197
	VISIT DATE: 05/07/2026

NARRATIVE

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Food Service

Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees °F and freezer 0-degree °C) with sufficient supply of 2-day perishable and 7 days non-perishable food. Fresh produce, proteins, and dry goods were stocked. Knives and were observed in a locked kitchen cabinet.

Health-Related Services & Records

Four (4) resident files were reviewed and contained current required documents including Admission Agreements, Pre-Placement Appraisals, Consents, Needs and Services Plans, Physician’s Reports with TB and ambulatory status, and Personal Rights acknowledgments. During record review, it was observed that R4 did not have a physician’s order for bed rails.

Threer (3) residents’ medications were reviewed and observed to be centrally stored in a locked closet near the front entrance. Centrally Stored Medication and Destruction Records were observed to be current.

Disaster Preparedness

Last fire/earthquake drill was conducted on March 06, 2026, with logs available. LIC 610D. Emergency supplies (water, food, flashlights, batteries, first aid) were observed in the garage. Infection Control Plan was updated.

Personnel Records & Training

Three (3) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. Administrator Certificate for Silvia Castro was valid through October 14, 2026..

Insurance

Liability insurance was in compliance with an expiration date of June 26, 2026.

An exit interview was conducted with Silvia Castro, Administrator. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/19/2026 11:16 AM - It Cannot Be Edited

Created By: Gabriela Castro On 05/07/2026 at 12:33 PM

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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST MATTHEWS HOME FOR THE ELDERLY	FACILITY NUMBER: 198602197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87633(j)(1)

(j) A written health condition exception request and approval from the Department in accordance with Section 87616, is not needed for any restricted health conditions listed in Section 87612, Restricted Health Conditions, or for any prohibited health conditions listed in Section 87615, Prohibited Health Conditions, provided the resident or prospective resident has been diagnosed as terminally ill and is currently receiving hospice care, in compliance with Section 87633, Hospice Care for Terminally Ill Residents, and the treatment of the restricted and/or prohibited health conditions is addressed in the hospice care plan. (1) In caring for a resident's health condition, facility staff, other than appropriately skilled health professionals, shall not perform any health care procedure that under law may only be performed by an appropriately skilled professional. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above, as R4 shared a bedroom with another resident while receiving hospice services, and a signed agreement consenting to the shared room arrangement was not available for review, which posed a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 05/18/2026
	Plan of Correction
1 2 3 4	Licensee shall obtain and maintain a signed agreement from R4, or the resident’s authorized representative, consenting to the shared bedroom arrangement while roommate is receiving hospice services. Licensee shall submit a copy of the signed agreement to CCL.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/19/2026 11:16 AM - It Cannot Be Edited

Created By: Gabriela Castro On 05/07/2026 at 12:46 PM

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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST MATTHEWS HOME FOR THE ELDERLY	FACILITY NUMBER: 198602197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in one (1) out of five (5) residents reviewed, as R4 did not have a physician’s order for bed rails, which posed a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 05/18/2026
	Plan of Correction
1 2 3 4	Administrator to obtain and submit a physicians order for R4's bedrails by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC809 (FAS) - (06/04)

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