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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602197
Report Date: 07/20/2023
Date Signed: 07/20/2023 05:02:04 PM


Document Has Been Signed on 07/20/2023 05:02 PM - 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:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Silvia Castro, administratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Administrator, Silvia Castro.and explained the purpose of today's visit. Facility is licensed to serve six (6) non-ambulatory residents, age 60 and above, of which one (1) maybe bedridden. Annual licensing fee is current. Administrator certificate is current and the expiration date is 10/14/23.

During the visit, CARE tool was used, a tour of the facility was conducted, food supply was reviewed, staff/resident files were reviewed, and medications were reviewed.



The facility is a single story house located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. The facility consisted of 4 residents bedroom, 2 1/2 bathrooms, dining room, kitchen, TV/living room, and family room. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 106.1 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. Sufficient supply of perishable and nonperishable foods was observed. A dual device of smoke detectors combined with carbon monoxide detectors were tested and operable. Fire extinguishers’ last service was 03/18/23 and fully charged. Medication were centrally stored in a locked storage room and inaccessible to residents. Resident records were stored in a locked storage room and inaccessible to residents.

No deficiencies were observed during the visit. An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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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