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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426745
Report Date: 11/19/2021
Date Signed: 11/19/2021 01:22:16 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2021 and conducted by Evaluator Jesse Gardner
COMPLAINT CONTROL NUMBER: 18-AS-20211117121227
FACILITY NAME:MATTHIAS HOMEFACILITY NUMBER:
336426745
ADMINISTRATOR:JAMES TOLANDFACILITY TYPE:
735
ADDRESS:13801 MOUNTAIN TOP DRIVETELEPHONE:
(760) 671-7421
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY:6CENSUS: 5DATE:
11/19/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer Ibarra, CaretakerTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Lack of staff resulted in resident leaving facility without supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Jesse Gardner, conducted an unannounced visit to the facility to commence a complaint investigation on the above allegation. The LPA was greeted by Jennifer Ibarra, and Brianna Bryant, Caretakers. They were informed of the purpose of the visit. There are currently no cases of COVID-19 in the facility.

Regarding the allegation, "Lack of staff resulted in resident leaving facility without supervision," it was alleged facility staff, on 11/17/21, failed to provide Resident One (R1) with adequate supervision resulting in the client eloping from the facility. LPA conducted interviews, reviewed records and took copies of pertinent information. Administrator Toland reported that there is one staff on the night shift on the day of incident, and as soon as Toland arrived on shift, they went looking for R1. Due to multiple occurances, a 1:1 was approved 11/1/21 and the facility has been looking to fill the position for R1 due to R1 needing constant supervision per the IPP. Staff/Client interviews were conducted and found that the allegation was SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations, (Title 22, Division 6 Chapter 1), are being cited on the attached LIC 9099D). An exit interview was conducted where this report, LIC 9099, LIC9099-D, and appeal rights were left with Toland.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20211117121227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MATTHIAS HOME
FACILITY NUMBER: 336426745
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2021
Section Cited
CCR
80078(a)
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80078(a) Responsibility for providing care and supervision. The Licensee shall provide care and supervision as necessary to meet the clients needs. This regulation is not being met as evidenced by: LPA reviewed files and determined the client needed a higher level of care that is not being met by facility.
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Licensee to increase supervision of client, and provide a plan by 11/20/21.
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This poses an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2