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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603050
Report Date: 09/08/2022
Date Signed: 09/09/2022 03:52:31 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/09/2022 03:52 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 #2FACILITY NUMBER:
198603050
ADMINISTRATOR:MATHARU, DAVEFACILITY TYPE:
735
ADDRESS:15335 CERISE AVETELEPHONE:
(310) 328-8482
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 3DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Laura RamirezTIME COMPLETED:
03:00 PM
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Licensing Program Analyst Pamela Bunker conducted an unannounced required annual visit. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked.

LPA Bunker met with Administrator Laura Ramirez. LPA Bunker informed staff that the purpose of today's visit is to conduct an annual inspection of the facility, review the physical plant, medications, food service, staff, and client records, and verify that the administrator is present at the property 20+ hours per week. LPA Bunker verified all current staff fingerprints cleared/associated with the facility. The facility annual fees are current. There are currently three (3) Westside Regional Center (WRC) consumers in placement. LPA verified that the facility has an approved mitigation plan report. The facility staff and clients are COVID-19 vaccinated and boosted. The facility's annual fees are current.

Ms. Ramirez and LPA Bunker made a complete tour of the facility. The facility is a single-story family home located in a residential neighborhood. The facility consisted of the following: Living room, dining area, office, kitchen, 5 bedrooms, 2 bathrooms, laundry area, attached garage, shaded area, and indoor/outdoor activity areas. Bedrooms #1 thru #5 are designated as the client's bedrooms.
See continued LIC 809-C on page #2
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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 #2
FACILITY NUMBER: 198603050
VISIT DATE: 09/08/2022
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Continued LIC 809-C page #2

Documents are posted as mandated on the facility living room bulletin boards. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. First aid kit is fully stocked with manual, hot water temperature 110 degrees Fahrenheit, working telephone, smoke and carbon monoxide detectors were in compliance, the fire extinguisher is fully charged, medications were centrally stored and properly locked in the dining area cabinet and records are current, ample supply of perishable and nonperishable food, adequate lights and linen supply, fire/emergency drill conducted on 07/24/2022. No firearms on the premises, the client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

The Administrator Certificate is current and expires 02/17/2024. HIV/TB is also, current and expires 05/06/2023. Staff was given training on dependent adult and elder abuse reporting.

LPA Bunker provided Ms. Ramirez with copies of the LIC809, LIC858, and LIC859.

There were no deficiencies cited.

Exit interview conducted
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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