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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602876
Report Date: 10/12/2024
Date Signed: 10/12/2024 04:18:50 PM


Document Has Been Signed on 10/12/2024 04:18 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:
10/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Caregiver Mildred LuwalhatiTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 10/12/24 and was greeted by Caregiver Mildred Luwalhati. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single-story dwelling.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible to residents in common bathroom #1. S2 removed disinfecting liquid after LPA Ramirez notified staff of violation. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers.

Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C).

Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in kitchen cabinets.



See 809-C
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/12/2024
NARRATIVE
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Residents with Special Needs: Pool with fenced gate and latch was observed in backyard. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. LPA Ramirez did not observe notification in R1, R2 or R3's resident record, from the licensee, that notified the Department in writing within five (5) working days of the initiation of hospice care services. Licensee has hospice waiver approved for two (2) residents only. R1, R2 and R3 are currently on hospice care. LPA Ramirez did not observe statement signed by R3 or R4's roommate, indicating his or her acknowledgement that their roommate (R2 & R3) intend to receive hospice care in the facility and their agreement to voluntary grant access to the shared living space to hospice caregivers, and the resident's support network of family members, friends, clergy and others.
Health Related Services/Incidental Medical Services: The medications are centrally stored and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.
Staffing: Administrator Sinclair’s personnel record was not made available during inspection. LPA Ramirez could not verify Administrator Sinclair’s administrator certificate. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. During inspection, LPA Ramirez observed S2 providing care and supervision to residents. LPA Ramirez requested S2’s personnel file, however, S2 revealed today was their first day working at the facility. Per back- up Administrator Michelle Aguirre, S2 is fingerprint cleared, however, S2 is only covering for another caregiver that called out ill. Administrator Michelle Aguirre revealed to LPA Ramirez that she received S2’s criminal clearance prior to S2 working at the facility. LPA Ramirez was able to verify S2 is criminally cleared through an internal process. LPA Ramirez did not observe criminal clearance, medical clearance, job application, CPR/First Aid or initial training for S2 during record review.

Personnel Records Training: Not all staff files are maintained at the facility and made accessible to LPA Ramirez during inspection. LPA Ramirez observed CPR and First Aid for one (1) out of the one (1) personnel record reviewed. LPA Ramirez did not observe TB testing results, Health screening, and job application for S1. During personnel record review, LPA Ramirez observed S1's documentation of training record to be blank.

Infection Control: Staff is using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 10/12/2024 04:18 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
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: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 6 out of 6 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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Staff removed disinfectant during inspection. *This clears 24 hour correction.**
Licensee will retrain staff on this regulation and send proof of retraining by 10/18/24, via email.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 10/12/2024 04:18 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
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: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
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 record review, the licensee did not comply with the section cited above in 6 out of 6 residents, staff, and/or visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will submit proof of liability insurance by 10/18/24, via email.
Type B
Section Cited
CCR
87632(d)(2)
Hospice Care Waiver
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee did not send the above information for R1,R2, and R2, the licensee did not comply with the section cited above in 3 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will send the above information for R1, R2 and R3 by 10/18/24, via email.
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 10/12/2024 04:18 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
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: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(2)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility is only approved for 2 hospice residents, however, the facility is providing care for 3 hospice residents, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will apply for hospice increase by 10/18/24. Licensee will certify plan to address how the facility plans to remain in compliance with terms and conditions of hospice waiver.

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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 10/12/2024 04:18 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
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: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(h)(5)
Hospice Care for Terminally Ill Residents
(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: (5) A statement signed by the resident's roommate, if any, or any resident who will share a room with a person who is terminally ill to be accepted or retained as a resident, indicating his or her acknowledgment that the resident intends to receive hospice care in the facility for the remainder of the resident's life, and the roommate's voluntary agreement to grant access to the shared living space to hospice caregivers, and the resident's support network of family members, friends, clergy, and others.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R3 & R4 roomates did not sign above acknowledgment, the licensee did not comply with the section cited above in 4 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will obtain written acknoledgment from R3 & R4's roommates. Proof must be submitted via email by 10/18/24
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 10/12/2024 04:18 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
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: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(13)(B)
87412 Personnel Records
(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).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, S2 did not have personnel file at the facility which documents criminal clearance, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Licensee will describe future plans to affirm and maintain ongoing complaince with this regulation. Proof must be submitted by 10/18/24, via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/12/2024
NARRATIVE
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Operational Requirements: The fire clearance is approved for six (6) non-ambulatory of which one (1) may be bedridden and reside in bedroom#3. This facility may retain no more than two (2) hospice residents. There are three (3) residents under hospice care during inspection. LPA Ramirez did not observe liability insurance for the facility during record review.

Resident Records/Incident Reports: LPA reviewed resident files for six (6) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. During resident records review, R4 & R5 did not have medical assessment in their file.

Six (6) violations were observed and cited during annual inspection. Exit interview conducted. A copy of this report, 809-D and appeals rights was provided via email.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024
LIC809 (FAS) - (06/04)
Page: 8 of 8