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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603049
Report Date: 06/24/2022
Date Signed: 06/24/2022 04:39:48 PM

Document Has Been Signed on 06/24/2022 04:39 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MATHARU HOME #1FACILITY NUMBER:
198603049
ADMINISTRATOR:GALEANO, ADRIANAFACILITY TYPE:
735
ADDRESS:15227 ROSELLE AVETELEPHONE:
(310) 328-8482
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 6CENSUS: 2DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Adriana GaleanoTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas met with staff Nelly Pineda and conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection. Administrator, Adriana Galeano arrived shortly after and assisted LPA, the purpose of todays visit was explained. The facility is licensed for six (6) non-ambulatory clients.

LPA met with the administrator and they both toured the inside and outside grounds of the facility. The one story residential house consists of four (4) bedrooms, living room, dining room with small office area, kitchen, two (2) full bathroom, bathroom #1 is equipped with shower bed ; bathroom #2 is equipped with a bathtub, laundry area, garage is located in the back of the property, and used as storage . Facility has backyard shaded patio area/ porch.

During the tour, LPA observed the facility’s infection control practices. LPA verified that the facility has an approved mitigation plan report. LPA was properly screened for Covid-19 symptoms, temperature was checked and documented. LPA observed a sanitizing station at the facility entrance. PPE supplies are readily available to staff, and an additional 90+ day supply of PPE was observed in the garage area. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the shaded backyard area. LPA observed all staff wear a face covering. LPA observed required postings throughout the facility. CCLD PINS were readily available to staff and clients.

All rooms were inspected, bedrooms are private, one client per room. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, the water temperature measured at 118.8 degrees F . Comfortable temperature was maintained in the

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MATHARU HOME #1
FACILITY NUMBER: 198603049
VISIT DATE: 06/24/2022
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facility LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept locked. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. Dual/ hardwired smoke detectors throughout the facility. LPA observed one (1) Fire Extinguisher mounted on the wall and fully charged, accessible, and inspected on 03/01/22. The First Aid kit was available and fully stocked. There are no security bars or weapons on the premises.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards, free of obstructions.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report to be provided to Adriana.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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