198602876-8-22-2023-28-AS-TVAO-CV6U9K-20230829152317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602876
Report Date: 08/22/2023
Date Signed: 08/22/2023 10:23:21 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20221026153715

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:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	Nenita Capistrano Caregiver		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility is not following Covid-19 safety protocols.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted a subsequent unannounced complaint investigation visit regarding the above allegation. LPA Flores met with Nenita Capistrano Caregiver and explained the reason for the visit.

The investigation consisted of the following: On 11/3/22 LPA Flores conducted a complaint investigation visit. LPA conducted a tour of the facility, interviewed residents #1-#6 (R1-R6), and staff #1-#2(S1-S2). On 1/18/23 LPA Flores contacted Michelle Aguirre to follow up on requested documents: staff roster, Caregiver schedules for the month of September, October, and November 2022, Trainings or In-services provided during 2022, Visitor’s log for September, October, November 2022 via email. On 8/22/23 LPA Flores delivered findings at the facility.

The investigation revealed the following: Regarding allegation: Facility is not following Covid-19 safety protocols. (CONTINUED LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221026153715

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 II	FACILITY NUMBER: 198602876
	VISIT DATE: 08/22/2023

NARRATIVE

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It is alleged, on 9/30/22 a witness observed a caregiver not wearing a mask or put a mask during the visit or while providing care to the residents. Staff did not screen representative for symptoms or have a sign-in procedure. Interviews with residents revealed, 1 out of 6 residents stated staff wears mask when providing direct care. 5 out of 6 residents were unable to answer due to cognitive skills. Interviews with staff revealed 2 out of 2 staff stated to wear a face mask while providing care. On 11/3/22 LPA Flores arrived at the facility at 9:10am and was allowed entry to the facility without being screen by S1. S1 was wearing a surgical mask under their chin, not covering the mouth or nose throughout the visit. LPA conducted a tour of the facility with S2, observed screening area to the right-hand side of entry door with visitor's log, hand sanitizer, and surgical mask, signs are posted by the entry area for symptoms, proper hand washing, and check for symptoms signs. PPE supplies were observed. at 9:40-10:00am LPA was requested to sign-in the visitor's log and staff roster, caregiver schedules, and staff files for review, which were not available at the facility for review. Documents were not available for review. LPA requested documents be email. On 1/3/23 LPA followed up via email requesting documents, documents were not provided to LPA. Per PIN 23-07 ASC, the masking requirements came to an end on March 3, 2023. Therefore, staff were required to properly use a face mask while at the facility. PIN 22-28 ASC Screening Protocols are to designate a facility staff to conduct initial screening for COVID 19 symptoms of all individuals entering the facility. During the visit of 11/3/22 LPA did not get screen by staff prior to entering the facility.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted and a copy of this report was provided, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221026153715

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 II	FACILITY NUMBER: 198602876
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/23/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will submit training provided to staff between September 2022 and February 2023 regarding COVID 19 protocols and will submit LIC 9098 certifying to adhere to 87468.1(a)(2) signed by licensee by POC due date 8/23/23.
	8 9 10 11 12 13 14	Based on observation licensee did not ensure staff did not wear mask properly as observed on visit conducted on 11/3/22 which poses an immediate risk to the health, safety, personal rights to the persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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