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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603080
Report Date: 08/09/2022
Date Signed: 08/12/2022 08:34:23 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/12/2022 08:34 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:
08/09/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Adriana Galeano, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual continuation 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 with ramp, indoor and outdoor activity area, laundry area, outside ramp for bedroom #3 and a detached garage.

LPA and House Manager Jimmy Portillo toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. All 5 bedrooms are occupied by clients and contain the mandated furniture. The (2) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector comply and operational. 1 staff file is current. The water temperature is at 106.7 degrees. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, (1) fire extinguishers is fully charged. First Aid kit complete and with manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MATHARU HOME #3
FACILITY NUMBER: 198603080
VISIT DATE: 08/09/2022
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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap in all bathrooms and additional sanitation/PPE's supplies stored in garage. LPA observed staff and clients wearing masks, if needed, isolation rooms will be clients bedrooms, and required postings throughout the facility. The administrator advised LPA that sanitizer is administered to client with the supervision of staff, but sanitizers are not kept in their rooms for safety reasons, trash can with lids, carts with PPE’s, Fit testing done for staff. The facility has an approved Mitigation plan. PPE's enough for 30 days. Visitors are logged and temperatures checked. The client’s temperatures are checked and logged 1x a day.

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.

No Technical Advisory (TA) issued.



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

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