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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603081
Report Date: 03/14/2022
Date Signed: 03/14/2022 02:17:35 PM

Document Has Been Signed on 03/14/2022 02:17 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:MATHARU HOME #4FACILITY NUMBER:
198603081
ADMINISTRATOR:MARTINEZ, YADIRAFACILITY TYPE:
735
ADDRESS:15330 EASTWOOD AVETELEPHONE:
(310) 355-1910
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 6CENSUS: 4DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Yadira MartinezTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas met with caregiver staff, Elena Borrayo and 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 verified that the facility has an approved mitigation plan report. LPA was later met with administrator, Yadira Martinez who assisted with the inspection. Facility is approved for six (6) non-ambulatory adults 18-59 years of age, facility prefers to serve Developmentally Disabled adults. There are currently four clients in care.

LPA and administrator both toured the inside and outside grounds of the facility. Facility is a one-story family home located in a residential area; facility has five (5) rooms (four (4) client rooms and one (1) room is used as an activity room) living room/ dining room with small office area, kitchen, three (3) full bathroom, bathrooms are equipped with shower, washbasin and toilet, Washer/Dryer area, garage is located in the front of the property, and used as storage area with extra refrigerator/ and freezer, backyard shaded area.


During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of clients and staff. PPE supplies are readily available to staff, and an additional 90+ day supply of PPE was observed. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed staff wear a face covering. LPA was informed that all staff and clients have been vaccinated and boosted. LPA observed required postings throughout the facility.

All rooms were inspected. Bedrooms are all private. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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
MONTERY PARK, CA 91754
FACILITY NAME: MATHARU HOME #4
FACILITY NUMBER: 198603081
VISIT DATE: 03/14/2022
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Client bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. The water temperature measured at 110.9 degrees F in client bathrooms. Comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food with extra over flow of food supply in garage. Knives and toxins were kept separate in a locked storage drawer/ cabinet. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. Carbon Monoxide and Smoke Detectors (connected) were tested. All alert systems are working properly. The facility (1) Fire Extinguisher was checked and found to be fully charged and accessible serviced on March 1, 2022. There are no security bars or weapons on the premises.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

No deficiencies were cited during this visit. Exit interview conducted. A copy of this report provided to administrator, Yadira Martinez.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
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