198603049-3-17-2023-11-AS-WGIS-CPZSW2-20230317141337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603049
Report Date: 03/17/2023
Date Signed: 03/17/2023 02:13:55 PM

Document Has Been Signed on 03/17/2023 02:13 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 #1		FACILITY NUMBER:	198603049
ADMINISTRATOR:	GALEANO, ADRIANA		FACILITY TYPE:	735
ADDRESS:	15227 ROSELLE AVE		TELEPHONE:	(310) 328-8482
CITY:	LAWNDALE	STATE: CA	ZIP CODE:	90260
CAPACITY: 6		CENSUS: 3	DATE:	03/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Adriana Galeano		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/17/2023, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced required annual visit using the full CARE Inspection Tools. LPA met with Administrator, Adriana Galeano, and explained the purpose of todays visit. The facility is licensed for six (6) non-ambulatory clients. Currently the facility has 3 residents and 1 was present during the inspection. Structure The facility is a single-story home located in a residential neighborhood. The facility consists of four (4) bedrooms, two (2) full bathrooms, living room, dining room, office area, laundry area, kitchen, and detached garage. Physical Plant LPA and administrator toured the inside and outside grounds of the facility. In the backyard, LPA observed a covered patio with table and chairs. All walkways and ramps have secured handrails. On the back of the property is an additional patio with a picnic table and two (2) sheds used for storage. In one (1) shed is an ample supply of incontinence product for residents, and in the second is an additional supply of cleaning supplies, sanitizer, and toiletries. Both sheds are locked and inaccessible to residents. In the garage is the facilities supply of Personal Protective Equipment (PPEs) and prepped outbreak carts. LPA did not observe any bodies of water on the premises. All walkways around the facility were observed to be clean, clear, and free of obstructions, debris, and hazards. Gate on the side is easily opened for exiting. Bedrooms LPA toured all bedrooms and found they contained the required furniture including bed, dresser, nightstand with lamp, a chair and ample storage space for resident’s belongings. All bedrooms are private. Residents have the option to supply personal furniture or use the furniture available by the facility. LPA observed two beds have half rails, LPA reviewed the exemption from Community Care Licensing and doctor’s orders. All rooms have ample lighting. Linens & Hygiene LPA observed all linens to be clean and in good repair. All beds had the required linens including mattress cover, fitted sheets, blankets, comforter and pillows. LPA observed an ample supply of linens and towels in the cupboards in the hallway and additional supply in the resident’s room. Some residents have chosen to purchase personal bed linens. Resident’s hygiene products are stored in a cabinet in the bathroom. Additional supply was observed in a storage shed in the backyard.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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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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: 03/17/2023

NARRATIVE

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Bathrooms LPA inspected both bathrooms and found them to be clean and sanitary. Both bathrooms have working wash basins, toilets, showers, and ample lighting. LPA observed both bathrooms to have secured safety handrails, nonskid mats, and shower chairs. LPA observed an ample supply of hand soap and paper towels. The water temperature measured between 116.2-degrees and 117.1-degrees Fahrenheit.
Kitchen LPA toured the kitchen and observed it to be clean and sanitary. LPA observed a three-day supply of perishable and a seven-day supply of non-perishable food. All appliances were in good working repair. LPA observed an ample supply of cutleries, pots, and pans to be in good repair. All knives and sharps were secured in a locked drawer. All toxins were secured in a locked cabinet under the sink. The water temperature measured 117.3-degrees Fahrenheit.
Common Rooms LPA observed ample seating in the living room to accommodate all residents. The dining room had a large rectangular table with ample spaces to accommodate all residents. LPA observed games, activities, and crafts available for residents in the hall cupboard and in a cabinet in the living room. All rooms had ample lighting. LPA observed all walkways to be clean, clear, and free of obstructions, and hazards. A comfortable temperature was maintained in the facility.
Safety LPA observed a fully charged fire extinguisher mounted on a wall in the living room last serviced on 03/01/23. The last emergency drill was conducted on 12/17/22, due to illness among the staff and in the facility. The smoke and carbon monoxide detectors and sprinkler system are fully operable and last serviced on 02/16/22. LPA observed the First Aid kit to be fully stocked with required items and a manual. All exits are clearly marked, and all rooms have a facility sketch posted on the walls, with exit routes and shut off valves marked. All required licensing posting were observed. There are no security bars on the premises. There are no firearms or ammunition stored on the premises.
Infection Control 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 upon entry, temperature was checked and documented. LPA observed a sanitizing station at the facility entrance with visitor, staff and resident log of temperature and screening questions. PPE supplies are readily available to staff, and an additional 90+ day supply of PPE was observed in the garage area as well as PPE carts. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed all staff wearing face covering. LPA observed required infection control postings throughout the facility. CCLD PINS were readily available to staff and clients.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC809 (FAS) - (06/04)

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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: 03/17/2023

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Medications Centrally stored medications were observed stored in their originally received containers and kept secured in a locked cabinet next to the office area and are inaccessible to residents in care. LPA reviewed all medications for residents and matched them to the MARs.

Files/Interviews LPA reviewed all resident files and found they contained the required documents. LPA reviewed five (5) staff files and found they contained the required documents, training, and certifications. LPA reviewed the facilities staff training log. LPA reviewed the residents P and I. LPA reviewed the facilities Surety Bond. LPA interviewed the Administrator, Direct Support Staff, and one (1) client who was present at the facility.

No deficiencies were cited during this visit.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC809 (FAS) - (06/04)

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