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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602876
Report Date: 09/07/2023
Date Signed: 09/07/2023 04:59:09 PM


Document Has Been Signed on 09/07/2023 04:59 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:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Nenita Capistrano- CaregiverTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting 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. Administrator, Michelle Aguirre was phoned and notified of the visit..
The facility is licensed to serve (6) elderly adults, ages 59 and above. It is approved for (6) non-ambulatory residents, of which (1) may be bedridden and reside in bedroom# 3 only. The facility also has a hospice waiver approved for (2).

The facility is a single-story home, located in a residential area. The home consists of (4) resident bedrooms, (2) resident bathrooms, (1) visitor bathroom, a kitchen, living room, dining room, tv room, attached garage, and a fenced pool.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.
During today's visit, LPA Maldonado obtained a copy of the client and staff roster, and conducted a tour of the physical plant with assistance of caregiver Nenita. The following was observed:
  • One central entry point for universal entry screening
  • Sufficient PPE stored for 30-days and readily available for use, throughout the home and stored in the garage
  • Physical plant inside and outside is clean, sanitary and in good repair
  • All walkways and pathways observed to be free of obstruction/hazards

(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: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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
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: 09/07/2023
NARRATIVE
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  • All resident bedrooms had the required furniture and the bedding had the required linens
  • Additional linens were observed in a linen closet in the hallway, inspected and in good repair.
  • Cleaning supplies and toxins were observed locked and inaccessible in the laundry room
  • Each client bathroom was equipped with a toilet, shower, and wash basin- all operational and in good repair.
  • Showers had the required grab bars and non-skid mats
  • The water temperature was tested and measured at 105.6*F in bathroom# 1 and 106.7*F in bathroom# 2
  • Sharps and knives were stored inaccessible in a closet near the kitchen.
  • At 1:30PM, LPA observed 2 kitchen knives and a pair of scissors in a drawer in the kitchen next to the sink where resident utensils are stored. Caregiver Nenita stated they're left there throughout the day and are placed back in the closet at the end of the day. LPA told her they should be inaccessible to residents at all times and she quickly placed them in the closet, locked and inaccessible.
  • At 1:31PM, Food supplies was inspected and LPA observed a quarter gallon of milk, one bottle of juice, a few yogurts and jellos, a few vegetables, and less than 24 eggs in the fridge- facility not in compliance with 2-day of perishables avilable for 6 residents in care
  • Dried and canned foods were observed and facility in compliance with 7-day non-perishables for 6 residents in care
  • Kitchen was observed clean/sanitary, and flatware, utensils, and cups were available and in good repair- sufficient for clients in care
  • All the required postings were posted throughout the home
  • The washing machine and dryer were observed in the garage and clean and operational at the time of the visit
  • 3 fire extinguishers were observed throughout the facility, fully charged with current inspections
  • At 1:43PM, LPA discovered that a closet located inside of Resident#6's private bedroom, was converted into a staff room. According to caregiver Nenita, staff rest there. The closet room is equipped with a bed, a TV, and storage space above the bed that has folded clothing throughout. It appears someone is occupying the room long-term.
  • At 1:45PM, LPA observed a padlock on the gate located on the side of the house that leads to the street. Caregiver was asked why the gate was locked, to which she responded that it is to keep wildlife out of the home. The facility does not have fire clearance for locked perimeters.
  • At 2:01, (6) resident files were reviewed, LPA found that files were not complete and were missing Admissions Agreements, Needs and Services Plans, Physician's Reports, and Pre-Placement Appraisals
  • It was discovered that (3) residents are currently on hospice, and the facility only has a waiver approved for (2)
  • It was also discovered that (6) residents have bedrails on their beds, however, only (3) have written orders indicating the need for them.

    • Per California Code of Regulations, Title 22, deficiencies were observed and will be cited during today's visit.
    Due to time constraints, LPA was unable to complete the annual inspection and will return at a later time to complete it and issue Civil Penalties for repeat violations within a 12 month period.
    An exit interview was conducted with caregiver Nenita Capistrano, and copy of the report and appeal rights was provided.
    SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
    LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 09/07/2023
    I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 09/07/2023
    LIC809 (FAS) - (06/04)
    Page: 2 of 8
    Document Has Been Signed on 09/07/2023 04:59 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: 09/07/2023

    DEFICIENCIES & PLANS OF CORRECTION (POCs)
    Type A
    Section Cited
    CCR
    87307(c)
    Personal Accommodations and Services
    (c) Individual privacy shall be provided in all toilet, bath and shower areas.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
    1
    2
    3
    4
    		Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in a staff room has been created inside a resident room, which poses an immediate health, safety or personal rights risk to persons in care.
    POC Due Date: 09/08/2023
    Plan of Correction
    1
    2
    3
    4
    		The licensee will remove all staff items and revert the closet to it's normal state as is noted in the facility sketch by the POC due date and will send LPA a pictue via email.
    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
    1
    2
    3
    4
    		Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 2 knoves and a pair of scissors were found in a drawer in the kitchen accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
    POC Due Date: 09/08/2023
    Plan of Correction
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    3
    4
    		Staff removed the items and placed them away while LPA observed. This deficiency is cleared.
    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: 09/07/2023
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 09/07/2023
    LIC809 (FAS) - (06/04)
    Page: 3 of 8


    Document Has Been Signed on 09/07/2023 04:59 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: 09/07/2023

    DEFICIENCIES & PLANS OF CORRECTION (POCs)
    Type A
    Section Cited
    CCR
    87555(b)(26)
    General Food Service Requirements
    (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
    1
    2
    3
    4
    		Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in insufficient 2-day perishables for 6 of residents, which poses an immediate health, safety or personal rights risk to persons in care.
    POC Due Date: 09/08/2023
    Plan of Correction
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    		Licensee will purchase food for residents and send a picture of the refrigerator filled with food as well as purchase receipts to LPA via email by the POC due date.
    Section Cited
    Deficient Practice Statement
    1
    2
    3
    4
    POC Due Date:
    Plan of Correction
    1
    2
    3
    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: Fernando FierrosTELEPHONE: (323) 981-3981
    LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
    LICENSING EVALUATOR SIGNATURE:
    		DATE: 09/07/2023
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 09/07/2023
    LIC809 (FAS) - (06/04)
    Page: 4 of 8


    Document Has Been Signed on 09/07/2023 04:59 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: 09/07/2023

    DEFICIENCIES & PLANS OF CORRECTION (POCs)
    Type B
    Section Cited
    CCR
    87208(a)(12)
    Plan of Operation
    (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
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    4
    		Based on [(observation) (interview) (record review)], the licensee was requested to submit an infection control plan to the licensing agency by 7/28/23 and has yet to receive it, 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 submit the infection control plan to LPA via email by the POC due date.
    Type B
    Section Cited
    CCR
    87506(a)
    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
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    2
    3
    4
    		Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [6 of 6 residents not having complete files, 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 send LPA a written plan of how will monitor and ensure resident files are maintained complete and at the facility at all times, 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: 09/07/2023
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 09/07/2023
    LIC809 (FAS) - (06/04)
    Page: 5 of 8


    Document Has Been Signed on 09/07/2023 04:59 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: 09/07/2023

    DEFICIENCIES & PLANS OF CORRECTION (POCs)
    Type B
    Section Cited
    CCR
    87457(c)(1)
    Pre-Admission Appraisal
    (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
    1
    2
    3
    4
    		Based on [(observation) (interview) (record review)], 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: 09/15/2023
    Plan of Correction
    1
    2
    3
    4
    		Licensee will submit a Pre-Placement plan for 6 residents to LPA via email by POC due date.
    Type B
    Section Cited
    CCR
    87458(a)
    Medical Assessment
    (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
    1
    2
    3
    4
    		Based on [(observation) (interview) (record review)], 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: 09/15/2023
    Plan of Correction
    1
    2
    3
    4
    		Licensee will submit a medical assessment for 6 residents in care 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: 09/07/2023
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 09/07/2023
    LIC809 (FAS) - (06/04)
    Page: 6 of 8


    Document Has Been Signed on 09/07/2023 04:59 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: 09/07/2023

    DEFICIENCIES & PLANS OF CORRECTION (POCs)
    Type B
    Section Cited
    CCR
    87507(d)
    Admisson Agreements
    (d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
    1
    2
    3
    4
    		Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in1 of 6 residents do not have an admissions agreement on file, which poses a potential health, safety or personal rights risk to persons in care.
    POC Due Date: 09/15/2023
    Plan of Correction
    1
    2
    3
    4
    		Licensee will submit an admissions agreementfor Resident# 1 to LPA via email by the POC due date.
    Type B
    Section Cited
    CCR
    87608(a)(3)
    Postural Supports
    (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
    1
    2
    3
    4
    		Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 3 residents not having a written order for bedrails indicating the need for it, which poses a potential health, safety or personal rights risk to persons in care.
    POC Due Date: 09/15/2023
    Plan of Correction
    1
    2
    3
    4
    		Licensee will obtain written orders for R1, R5, and R6 to use bed rails on their beds, sent 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: 09/07/2023
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 09/07/2023
    LIC809 (FAS) - (06/04)
    Page: 7 of 8


    Document Has Been Signed on 09/07/2023 04:59 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: 09/07/2023

    DEFICIENCIES & PLANS OF CORRECTION (POCs)
    Type B
    Section Cited
    CCR
    87633(a)(1)
    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: (1) The licensee has received a hospice care waiver from the department.

    This requirement is not met as evidenced by:
    Deficient Practice Statement
    1
    2
    3
    4
    		Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 3 residents in care on hospice and facility only has approval for 2, which poses/posed a potential health, safety or personal rights risk to persons in care.
    POC Due Date: 09/15/2023
    Plan of Correction
    1
    2
    3
    4
    		Licensee will submit a written request to retain more hospice residents than currently, to LPA via email by POC due date.
    Section Cited
    Deficient Practice Statement
    1
    2
    3
    4
    POC Due Date:
    Plan of Correction
    1
    2
    3
    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: Fernando FierrosTELEPHONE: (323) 981-3981
    LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
    LICENSING EVALUATOR SIGNATURE:
    		DATE: 09/07/2023
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 09/07/2023
    LIC809 (FAS) - (06/04)
    Page: 8 of 8