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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603080
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:51:58 PM

Document Has Been Signed on 04/17/2024 03:51 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 #3FACILITY NUMBER:
198603080
ADMINISTRATOR/
DIRECTOR:		ADRIANA GALEANOFACILITY TYPE:
735
ADDRESS:2420 W 156TH STTELEPHONE:
(310) 328-8482
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY: 6CENSUS: 4DATE:
04/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Adriana Galeano, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 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 Adriana Galeano 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, den, 4 bedrooms, 2 bathrooms, laundry area, detached garage, shaded area, and indoor/outdoor activity areas. Bedrooms #1 thru #4 are designated as the client's bedrooms.

LPA Shirley and Adriana walked through the kitchen and all appliances were in good working order. Knives were locked and stored in a drawer 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 109.9 degrees Fahrenheit.

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

LPA Shirley and Adriana 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 Adriana toured the backyard. There is shade, no bodies of water and no obstructions near the gates.

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 #3
FACILITY NUMBER: 198603080
VISIT DATE: 04/17/2024
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LPA Shirley and Adriana 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. Medications are stored, locked and inaccessible to residents. (1) Resident files along with medications are current. (1) Staff files are current. This facility is in good repair.

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 Adriana Galeano, 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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