198602876-9-20-2022-28-AS-VMAO-CJFSFW-20220920135102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602876
Report Date: 09/20/2022
Date Signed: 09/20/2022 01:51:20 PM

Document Has Been Signed on 09/20/2022 01:51 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 ELDERLY II		FACILITY NUMBER:	198602876
ADMINISTRATOR:	SINCLAIR, REBECCA		FACILITY TYPE:	740
ADDRESS:	2408 SAN JACINTO COURT		TELEPHONE:	(626) 253-5806
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 6	DATE:	09/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Nenita Capistrano- Caregiver		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) V. Maldonado made an unannounced required 1 year visit to conduct the annual inspection. LPA Maldonado met with caregiver Nenita Capistrano and explained to purpose for the visit. Caregiver phoned assistant administrator Michelle Aguirre and informed her of the visit. LPA used the infection control tool to evaluate the facility. During today's visit, LPA toured the physical plant with caregiver Nenita, food and PPE supplies were observed, COVID-19 procedures were reviewed, staff files were checked for criminal background clearance and training, and residents' medications and files were reviewed for updated emergency information. The facility is licensed for 6 non-ambulatory residents, age range 60 and over -1 may be bedridden and hospice waiver has been approved for 2 residents. Currently there are 6 residents residing in the facility and 4 are on hospice. The assistant administrator Michelle Aguirre arrived at the middle of the visit and assisted with the rest of the visit. The facility consists of 4 bedrooms, 3 bathrooms, a living room, a kitchen, a dining room, a TV room, a backyard with a shaded patio, a body of water was observed in the back yard, and an attached garage. During the tour, LPA observed all walkways, pathways, and entrance/exits free of debris, obstructions, and hazards. There is COVID-19 signage throughout the facility promoting handwashing, social distancing and mask wearing. PPE and hand sanitizer was readily available throughout the facility for resident use. LPA observed the food supplies in the kitchen to be the required 2-day of perishables and 7-day of non-perishables, with a variety of nutritious foods. Medications and sharps were observed to centrally stored and locked in a closet next to the kitchen, inaccessible to residents in care. LPA observed bathrooms#1-#2 to have a working toilet, shower, and wash basin. At 9:17 a.m., bathroom# 2's toilet was observed to not be in good repair as the toilet had no toilet seat or a top pump cover. Bathroom# 2 was also observed to not have a private door and leads to a hallway with a private room. The asst. administrator was asked about this and states the restroom is used only for the one resident with the private room in that area. (Report Continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ELDERLY II	FACILITY NUMBER: 198602876
	VISIT DATE: 09/20/2022

NARRATIVE

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All bedrooms had the required linens, furniture, and storage space for resident use. The linen closet was observed in the hallway with sufficient additional linens for resident use. The laundry room was observed to have operating machines and in good repair. Cleaning supplies and toxins were also stored in the laundry room, which remains locked and inaccessible to residents in care. A door in the laundry room led to the attached garage which was used for additional storage. Face masks were observed in the garage and additional adult briefs for residents. A fire extinguisher was observed in the kitchen and in the laundry room, operational and fully charged.

At 10:22 a.m., LPA reviewed resident files and observed (3) of (6) residents' files to be missing some of the required documents. (2) of (6) dementia care residents do not have an updated physician's report. It was also discovered that there are 2 more residents on hospice than the facility is currently approved for. During review of staff files, LPA observed (2) of (3) resident files to be incomplete and (1) of (3) staff files was not at the facility during the time of the visit. (3) of (3) staff working at the facility during the time of the inspection were found to not be associated to the facility. The administrator was asked about this and states that the 1 staff with no file is only staying here for now. He arrived "last night" and she is not sure if they are going to hire that staff yet.

Per Title 22, California Code of Regulations, deficiencies were observed during today's visit and will be cited respectively on the LIC809-D.

Immediate Civil Penalties will also be issued in the amount of $500 per each staff (3) that were present and not associated to the facility, during the time of the visit.

An exit interview was conducted with assistant administrator Michelle Aguirre and caregiver Nenita Capistrano, and a copy of this report and appeal rights were issued.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/20/2022 01:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ELDERLY II	FACILITY NUMBER: 198602876
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(6)

87303 Maintenance and Operation (e)Water supplies and plumbing fixtures shall be maintained as follows:(6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above when LPA observed the toilet in bathroom# 2 was not in good repair as it was missing the toilet seat and top pump cover, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2022
	Plan of Correction
1 2 3 4	Administrator will obtain a cover for the top pump and toilet seat and will repair it. A picture of the correction will be faxed to LPA by the POC due date.

Type A

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance (e)All individuals subject to a criminal record review…shall prior to working, residing or volunteering in a licensed facility:(2)Request a transfer of a criminal record clearance… 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 3 of 3 staff working at the facility were present without being associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2022
	Plan of Correction
1 2 3 4	Adminstrator will submit LIC9182 Criminal Background Clearance Transfer Request for each staff with the respective documents and ID's to associate them, as she states she is unable to access Guardian for now.

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

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/20/2022 01:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ELDERLY II	FACILITY NUMBER: 198602876
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87632(a)

87632 Hospice Care Waiver (a)In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. 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 LPA discovered that the facility has an approved hospice waiver for 2, but currently has 4 residents on hospice, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2022
	Plan of Correction
1 2 3 4	The administrator will submit a request to LPA by fax, for a request in increase of hospice waiver to accomodate the current residents they have on hospice, completed by POC date.

Type B

Section Cited

CCR

87506(a)

87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 aboveas LPA observed 3 of 6 resident files to be missing required documentation, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2022
	Plan of Correction
1 2 3 4	The administrator will complete and submit a copy of completed resident files to LPA via fax, by the POC date.

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

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 09/20/2022 01:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ELDERLY II	FACILITY NUMBER: 198602876
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)&(c)

87412 Personnel Records (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11)A health screening… (c)Licensees shall maintain in the personnel records verification of required staff training and orientation. 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 3 of 3 staff files being incomplete, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2022
	Plan of Correction
1 2 3 4	The administrator will complete and submit a copy of completed staff files to LPA via fax, by the POC date.

Type B

Section Cited

CCR

87705(c)(5)

87705 Care of Persons with Dementia (c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5)Each resident with dementia shall have an annual medical assessment… and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. 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 2 of 6 residents with dementia did not have an updated medical assessment or reappraisal in their file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2022
	Plan of Correction
1 2 3 4	Administrator will schedule and obtain an updated medical assessment for residents with dementia. A copy of the udpated records will be faxed to LPA by the POC due date.

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

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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