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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426745
Report Date: 11/19/2021
Date Signed: 11/19/2021 01:26:21 PM

Document Has Been Signed on 11/19/2021 01:26 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:James Toland, AdministratorTIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to the facility to conduct a complaint investigation (18-AS-20211117121227). During the review of resident files, LPA discovered that medication was not being administered as required per the physician's orders. Due to this finding, California Code of Regulations, (Title 22, Division 6 Chapter 1), are being cited on the attached LIC 9099D.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2021 01:26 PM - It Cannot Be Edited


Created By: Jesse Gardner On 11/19/2021 at 12:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
11/20/2021
Section Cited
CCR
80075(b)

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80075(b) Health Related Services. Clients shall be assisted as needed with self-administration of prescription and non-prescription medications. This requirement is not being met as evidenced by: During LPA's investigation, LPA observed medication not being administered as prescribed.
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Licensee to administer medication as prescribed by physician. Submit proof by screenshot of updated MARS 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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