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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426745
Report Date: 03/10/2022
Date Signed: 03/10/2022 10:41:44 AM

Document Has Been Signed on 03/10/2022 10:41 AM - 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:
03/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ericka Munoz, AdministratorTIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner was at the facility on an unannounced visit investigating an unrelated complaint (18-AS-20220308120737).

While at the facility, LPA discovered an employee who had not had a fingerprint clearance, thus a Type A violation and a civil penalty was issued in the amount of $500 per Title 22 Division 6 Chapter 1, Article 3 Criminal Record Clearance 80019(e)(1).

Administrator Ericka Munoz stated that the involved employee Annimae Thomas began working in the facility on 2/3/2022 and conducted duties consisting of verifying medications and consumer notes, conducting client checks, and cleaning the facility.

An exit interview was conducted and a copy of this report, along with copies of LIC421BG, and Appeal Rights were issued.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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 03/10/2022 10:41 AM - It Cannot Be Edited


Created By: Jesse Gardner On 03/10/2022 at 10:15 AM
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: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2022
Section Cited
CCR
80019(e)(1)

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CRIMINAL RECORD CLEARANCE:(e) All individuals subject to a criminal record..prior to working...(1) Obtain..Licensee did not adhere to the regulation as evidenced by:
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Ms. Thomas was terminated effective 3/10/22 for not conducting her duties. Licensee will review the regulation and self-certify that they understand by submitting email proof to LPA by 3/11/22.
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Based on LPAs record review, Licensee did not ensure employee had a fingerprint clearance prior to working. This poses an immediate health and safety and personal rights risk to residents 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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022


LIC809 (FAS) - (06/04)
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