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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602876
Report Date: 09/08/2023
Date Signed: 09/08/2023 01:21:55 PM


Document Has Been Signed on 09/08/2023 01:21 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 IIFACILITY NUMBER:
198602876
ADMINISTRATOR:SINCLAIR, REBECCAFACILITY TYPE:
740
ADDRESS:2408 SAN JACINTO COURTTELEPHONE:
(626) 253-5806
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
09/08/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nenita Capistrano- CaregiverTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) V. Maldonado made a subsequent visit to the facility for the purpose of completing the required annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA met with caregiver, Nenita Capistrano and explained the purpose for the visit.

During today's visit, LPA Maldonado observed the following:

At 10:14AM, (4) staff files were reviewed for required documentation. It was discovered that Staff# 1-2 (S1-S2) files did not have health screenings and proof of completed required annual training. It was also discovered that files for Staff# 3-5 (S3-S5) were not available for LPA to inspect. Per S1, files for S3-S5 are with S3 and S3 is currently on vacation. At 10:20AM, S1 confirmed with LPA that S4-S5 are currently employed at the facility and their work schedule is 7AM-7PM, Saturday and Sunday, but may sometimes alternate depending on the need for staff. After review of the Facility Personnel Report Summary, it was noted that S4-S5 are not associated to the facility.

LPA Maldonado was also unable to determine who the administrator for the facility is, as per licensing records, Rebecca Sinclair is listed as the Administrator, but staff Michelle Aguirre has informed LPA during the annual inspection in 2022 that she is the Administrator. The licensing agency has not been provided records to request a change in administrator, and there is no proof of a current and valid administrator certificate at the facility or file for an administrator available for LPA to inspect.

Six (6) resident medications and Centrally Stored Medication and Destruction Records were inspected and reviewed. It was determined that medications are documented properly and administered as prescribed.

(Report Continued on LIC809-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
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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Document Has Been Signed on 09/08/2023 01:21 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: 09/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having the administrator being present at the facility during normal working hours, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2023
Plan of Correction
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Licensee will submit a written plan and schedule indicating how they will comply with having the adminstrator at the facility sufficient time during normal business hours to be responsible for the operations of the facility and who their designee is/will be in case administrator is not available (LIC308). Send to LPA via email by POC due date.
Type A
Section Cited
CCR
87412(a)(13)(B)1
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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in maintaining proof of a current and valid adminstrator certificate available at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2023
Plan of Correction
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Licensee will provide LPA with the facility administrator current and valid certificate and will submit additional request to update adminstrator, if changes are needed, to LPA via email by 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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2023 01:21 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: 09/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in making available staff records for 3 of 5 staff, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee will submit a written plan on how the facility will ensure to maintain all staff records readily available for licensing agency to inspect during normal business hours. Submit to LPA via email by POC due date.
Type B
Section Cited
CCR
87412(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 3 of 5 staff files were not maintained on the administrator and 2 staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee will create a file and keep at the facility for all staff employed at the facility. A copy of files for administrator and S4-S5 will be provided to LPA via email by 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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 09/08/2023 01:21 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: 09/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
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 as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 avilable staff files did not have health screenings, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Proof of Record of Health Screening for S1-S2 will be emailed to LPA via email by POC due date.
Type B
Section Cited
CCR
87412(c)
Personnel Records
(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
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Based on observation and record review, the licensee did not comply with the section cited above in 2 available staff files reviewed did not have proof of required staff training and orientation, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee will email LPA proof of required annual training and orientation records for S1-S5, by 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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


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: 09/08/2023
NARRATIVE
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LPA attempted to conduct interviews with (6) residents, however was unable to due to cognitive impairments, unresponsive to LPA, and/or sleeping.
(2) staff interviews were conducted with available staff.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit and will be cited on the LIC809-D pages.

Additionally, Immediate Civil Penalties will be issued in the amount of $1,500 were issued today, for repeat violations within a 12-month period and for staff who are not associated and working at the facility.

An exit interview was conducted with caregiver Nenita Capistrano and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 09/08/2023 01:21 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: 09/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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… in a licensed facility: (2)Request a transfer of a criminal record clearance…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 staff not being associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2023
Plan of Correction
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Licensee will provide LPA with S4 and S5's request for transfer of criminal record clearance, copies of Identification, and criminal record statemen, via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 09/08/2023 01:21 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: 09/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(7)(A)
87208 Plan of Operation
(a)… The plan and related materials shall be on file in the facility... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval...: (7)Sketches, showing dimensions, of the following:(A)Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in submitting a change of facility sketch for the room proposed for staff use, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee will submit a new facility sketch to licensing, requesting approval to use the closet as a propsed room designated for staff use, to LPA via email by the POC due date.
Type B
Section Cited
HSC
1569.605
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in providing licensing with a copy of their current and valid liability insurance information, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee will submit proof of the current and valid liability insurance for the facility to LPA via email 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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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