<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004368
Report Date: 03/24/2022
Date Signed: 03/24/2022 04:20:50 PM


Document Has Been Signed on 03/24/2022 04:20 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:MATSONIA LANE HOMESFACILITY NUMBER:
306004368
ADMINISTRATOR:MYLENE GABATFACILITY TYPE:
740
ADDRESS:19691 MATSONIA LANETELEPHONE:
(714) 965-2710
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 4DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Administrator, Mylene GabatTIME COMPLETED:
04:30 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 this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and was granted entry into the facility by Staff. LPA observed a check in table upon entry which contained hand sanitizer and masks. LPA explained the reason for the visit.

LPA Tirre toured the facility at 2:51 PM with Caregiver Cathy Mones. Facility is a 5 bedroom 2 bathroom single story home. At time of visit there were four Residents in care. LPA observed residents relaxing in bedrooms and watching TV in dining area. Residents appeared clean in appearance. LPA observed facility has required Department postings. Proper hand washing signs posted in facility restrooms. All restrooms observed contained working water basin, soap, toilet paper and hand towels. LPA observed locked areas for toxins and hazardous items. LPA toured Resident rooms, rooms where within regulations.



LPA observed the emergency disaster and evacuation plans posted. LPA observed Administrator certificate expiring 11/19/22. Facility has refrigerator and pantry with ample food supply. LPA observed facility has emergency food and water supply. Facility has 1 fire extinguisher which is mounted and fully charged. Facility has audible alarms for each sliding door entrance/exit. Facility has some supply of PPE. LPA reminded Administrator importance of 30 days supply. Facility has a secured location for Resident medication and files. Facility has 30 days’ supply of medications for Residents. LPA reviewed 4 of 4 Resident files during visit. Resident emergency contact information and physician’s reports are current. Facility has designated visitation areas.

No deficiencies noted during this visit. An exit interview was conducted with Administrator and a copy of report was left at facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1