198603081-3-16-2023-11-AS-WGIS-CPYRXA-20230316132425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603081
Report Date: 03/16/2023
Date Signed: 03/16/2023 01:24:37 PM

Document Has Been Signed on 03/16/2023 01:24 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	MATHARU HOME #4		FACILITY NUMBER:	198603081
ADMINISTRATOR:	MARTINEZ, YADIRA		FACILITY TYPE:	735
ADDRESS:	15330 EASTWOOD AVE		TELEPHONE:	(310) 355-1910
CITY:	LAWNDALE	STATE: CA	ZIP CODE:	90260
CAPACITY: 6		CENSUS: 4	DATE:	03/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Yadira Martinez		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/16/23, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced required annual visit using the CARE Inspection Tools. Upon arrival at the facility, LPA Gibbs met with Administrator, Yadira Martinez, and explained the purpose of this visit. LPA was properly screened for Covid-19 symptoms and temperature was checked. LPA verified that the facility has an approved mitigation plan report. 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 (4) clients in care and two (2) were present during the visit. Structure Facility is a one-story family home located in a residential area; facility has four (4) client rooms, activity room, living room, dining room with small office area, kitchen, three (3) full bathrooms, laundry room, and a garage located in the front of the property. Physical Plant LPA and administrator toured the inside and outside grounds of the facility. LPA observed a table, chairs, umbrella, and chair swing on the side patio. All walkways were clean, clear, and free of obstructions, hazards, and debris. There are no bodies of water on the premises. Bedrooms LPA inspected all rooms. All bedrooms are private. All rooms had the required furniture including a bed, dresser, nightstand, chair, and storage space for personal belongings. Two beds had half side rails, per physician’s orders. Beds and bedding supplies were in good condition. LPA observed all beds had the required linens including a mattress cover, fitted sheets, blankets, comforter, and pillow. Additional linens were observed in resident’s closets and on shelving in the laundry room. LPA observed ample lighting provided in bedrooms. Bathroom LPA inspected all bathrooms. All bathrooms are equipped with a shower, washbasin, and toilet. All bathrooms were observed to have ample hand soap and paper towels. All bathrooms had secured safety handrails in the showers and next to the toilets. All showers had nonskid mats and shower chairs. LPA observed toiletry baskets stored on a shelve in the resident’s closets and additional supply in a cabinet in the dining room and storage room. The hot water temperature in the bathrooms measured between 105.5-degrees to 109.9-degrees Fahrenheit. All bathrooms were found to be clean and sanitary at time of visit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MATHARU HOME #4	FACILITY NUMBER: 198603081
	VISIT DATE: 03/16/2023

NARRATIVE

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Kitchen LPA toured the kitchen area and observed it to be clean and sanitary. All appliances were in good working repair. LPA observed an ample supply of cutleries, pots, and pans in good repair. LPA observed a 3-day supply of perishable and a 10-day supply of non-perishable food. Additional, supply of food and emergency food is stored in a cabinet in the garage and in an extra refrigerator and freezer. Knives and toxins were kept separate. Knives are locked in a drawer and cleaning supplies are locked in a cabinet under the sink. The water temperature measured 107.2-degrees Fahrenheit.

Common Rooms LPA observed ample seating in the living room to accommodate all residents. The dining room has a large table to accommodate all residents and staff assisting residents to seat comfortably and to spread out. The activity room has space to accommodate all residents. LPA observed an ample supply of games, activities, and crafts for residents. Additionally, there is a Wii for residents to play. All rooms and hallways had ample lighting. LPA observed all walkways and hallways to be clean, clear, and free of obstructions and hazards.

Safety LPA observed all exits clearly marked. All room have the facility sketch with evacuation plan and shut off switches marked. All smoke/carbon monoxide detectors are operable. LPA observed a fully charged fire extinguisher mounted on the wall in the living room, last serviced on 03/01/23. The last emergency drill was conducted on 02/24/23. The sprinkler system was last serviced in December of 2022. LPA observed all required licensing postings throughout the facility. The facility has a working landline telephone. LPA inspected both First Aid kits and found they were fully stocked and had the required items including the manual. One was stored in the medication cabinet and the other in a grab-and-go bag secured in a cabinet in the dining room. There are no security bars over the window. No firearms or ammunition are stored on the premises.
Infection Control During the tour, LPA observed the facility’s infection control practices. LPA was screened for Covid before entering the facility. 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 stored in the garage. Sufficient paper, cleaning, and disinfecting supplies were observed in the storage room on the side of the home. LPA observed staff wear a face covering. LPA was informed that all staff and clients have been vaccinated and boosted. LPA observed required infection control postings throughout the facility.
Medications All medications were observed stored in their originally received containers. Medications are kept safe, secured, and inaccessible to residents, stored in a locked cabinet in the garage. LPA reviewed all resident’s medications and matched them to the MARs.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MATHARU HOME #4	FACILITY NUMBER: 198603081
	VISIT DATE: 03/16/2023

NARRATIVE

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Files/Interviews LPA reviewed all resident’s files and found they contained the required documents. LPA reviewed 6 staff files and found they contained the required documents, certification, and training. LPA reviewed the facilities training logs, which are conducted twice a month. LPA reviewed the P&I record for all residents. LPA reviewed the Surety bond through CNA Surety, bond number: 14574089 that expires on 03/31/2024. LPA conducted 2 staff interviews and 2 resident interviews.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

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