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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603080
Report Date: 07/12/2022
Date Signed: 07/13/2022 11:28:04 AM

Document Has Been Signed on 07/13/2022 11:28 AM - 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:MATHARU HOME #3FACILITY NUMBER:
198603080
ADMINISTRATOR:ADRIANA GALEANOFACILITY TYPE:
735
ADDRESS:2420 W 156TH STTELEPHONE:
(310) 328-8482
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 5DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Adriana Galeano, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA's) Ana Soto and Scott Perry conducted an unannounced Annual inspection and infection control inspection visit to the above facility. LPA was met by Jimmy Portillo, House Manager and later met with Adriana Galeano , Administrator and the purpose of today’s visit was explained.

There are currently (5) Westside Regional Center consumers in placement. All (5) clients are non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 2 bathrooms, family room/office, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry area and a detached garage.

LPA and House Manager Jimmy Portillo toured the entire facility inside and out. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. 1 resident file is current along with medications.

Due to time constraints LPA's could not complete annual, LPA will return at a later date. If any deficiencies noted they will be cited at that time.

An exit interview was conducted with Adriana Galeano , Administrator and a hard copy was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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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