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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603081
Report Date: 03/25/2024
Date Signed: 03/25/2024 12:55:10 PM

Document Has Been Signed on 03/25/2024 12:55 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, 1000 CORPORATE DR #100
MONTEREY 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:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:TIME COMPLETED:
01:00 PM
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On 03/25/24, 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. 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 they were attending day program 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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MATHARU HOME #4
FACILITY NUMBER: 198603081
VISIT DATE: 03/25/2024
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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 109.5-degrees to 109.1-degrees Fahrenheit. All bathrooms were found to be clean and sanitary at time of visit.
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, dishware, and cookware in good repair. LPA observed a 5-day supply of perishable and a 10-day supply of non-perishable food. All food was observed to be stored, packaged, labeled and dated. Additional, supply of food and emergency food is stored in a cabinet in the garage and in an extra refrigerator and freezer. LPA observed knives and other sharps to be secured in a locked drawer and are inaccessible to clients. LPA observed all toxins and cleaning supplies secured in a locked cabinet under the sink and are inaccessible to clients. The water temperature measured 109.2-degrees Fahrenheit.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MATHARU HOME #4
FACILITY NUMBER: 198603081
VISIT DATE: 03/25/2024
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Sufficient paper, cleaning, and disinfecting supplies were observed in the storage room on the side of the home. LPA observed staff wearing face covering. LPA was informed that all staff and clients have been vaccinated and boostered. LPA observed required infection control postings throughout the facility.
Medications All medications were observed stored in their originally received containers. Medications are secured in a locked cabinet in the garage and are inaccessible to clients. LPA reviewed medication for all clients, LPA observed four (4) out of four (4) client’s MARs and medication are consistent with properly documented records.
Files/Interviews LPA reviewed all client’s files and found they contained the required documents. LPA reviewed four (4) staff files and found they contained the required documents, certification, and training. LPA reviewed the facilities training logs and in-service logs, which are conducted twice a month. LPA reviewed the P&I record and receipts for all clients for the month of January, February, and March. LPA reviewed the Surety bond through CNA Surety, bond number: 14574089 that expires on 03/31/2024. LPA conducted 1 staff interview and they were able to answer question regarding client care, procedure, policy, and client personal rights. Administrator was informed Licensing Fees are due on 03/27/24. Licensee informed LPA the payment was submitted via mail on 03/03/24 via check 34284 for the full amount.

No deficiencies were observed or cited during today’s visit. An exit interview was conducted, and a copy of this report was emailed to administrator, Yadira Martinez.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC809 (FAS) - (06/04)
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