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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603050
Report Date: 04/17/2024
Date Signed: 04/17/2024 12:17:44 PM

Document Has Been Signed on 04/17/2024 12:17 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:MATHARU HOME #2FACILITY NUMBER:
198603050
ADMINISTRATOR/
DIRECTOR:
MATHARU, DAVEFACILITY TYPE:
735
ADDRESS:15335 CERISE AVETELEPHONE:
(310) 328-8482
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 4DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Laura Ramirez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 4/17/2024, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Laura Ramirez/Administrator and the purpose of today’s visit was explained.

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, 4 bedrooms, 2 bathrooms, office, activities room, laundry area, attached garage, shaded area, and indoor/outdoor activity areas. Bedrooms #1 thru #4 are designated as the client's bedrooms.

LPA Shirley and Laura walked through the kitchen and all appliances were in good working order. Knives were locked and stored in the disaster cabinet located in the kitchen and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 105.9 degrees Fahrenheit.

All bathrooms were checked, toilets and water faucets worked properly. The showers were free of mildew and mold.

LPA Shirley and Laura walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen.

LPA Shirley and Laura toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. (1) Resident file along with medications are current. (1) Staff file is current. The facility is in good repair.

Con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: MATHARU HOME #2
FACILITY NUMBER: 198603050
VISIT DATE: 04/17/2024
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PPE's will last for 30 days plus.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Laura Ramirez, Administrator and a hard copy of report provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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