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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602876
Report Date: 08/31/2023
Date Signed: 08/31/2023 03:24:17 PM


Document Has Been Signed on 08/31/2023 03:24 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ST MATTHEWS HOME FOR THE ELDERLY IIFACILITY NUMBER:
198602876
ADMINISTRATOR:SINCLAIR, REBECCAFACILITY TYPE:
740
ADDRESS:2408 SAN JACINTO COURTTELEPHONE:
(626) 253-5806
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
08/31/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Nenita CapistranoTIME COMPLETED:
03:40 PM
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Licensing Program Analyst(s)(LPA) Mary Flores and Nune Margaryan conducted an unannounced Plan of Correction (POC) visit regarding deficiencies noted on 8/22/23.

On 8/22/23 LPA Flores conducted a complaint investigation visit and noted the following deficiency:
Section CCR 87468.1(a)(2) Personal Rights of Residents in All Facilities: On 8/22/23 LPA requested training provided to staff between September 2022 and February 2023 regarding COVID 19 protocols and LIC 9098 certifying to adhere to 87468.1(a)(2) signed by licensee to be submitted by POC due date 8/23/23. Documents were not received by the department by POC due date.

*Civil Penalties were assess for $700 dollars.*

On 8/22/23 LPA Flores conducted a case management visit -deficiencies and noted the following deficiency:
Section CCR 87411(c)(6) Personnel Requirements - General: On 8/22/23 LPA requested licensee to certify on LIC 9098 that files will be available for review at the facility and submit LIC 9098 and trainings provided between September 202 and February 2023 by POC due date 8/29/23. Documents were not received by the department by POC due date.

*Civil Penalties were assess for $100 dollars.*

*Civil Penalties were assess for a total of $800 dollars during this visit.*

Exit interview was conducted and a copy of this report and Civil Penalties were provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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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