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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336426745
Report Date: 12/04/2023
Date Signed: 12/04/2023 09:57:14 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
10/09/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231009143347
FACILITY NAME:MATTHIAS HOMEFACILITY NUMBER:
336426745
ADMINISTRATOR:ADILENE QUINTANILLAFACILITY TYPE:
735
ADDRESS:13801 MOUNTAIN TOP DRIVETELEPHONE:
(760) 671-7421
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY:6CENSUS: 5DATE:
12/04/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Alexis Parker, Lead StaffTIME COMPLETED:
09:56 AM
ALLEGATION(S):
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Staff did not notify authorized representative that client went to hospital
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Lead Staff Alexis Parker and informed them of the purpose of this visit. During this investigation, LPA conducted interviews with staff and clients; obtained supportive documentation for review to assist with determining the findings for the above noted allegation. The following was determined.

Allegation# 1 - An allegation received stated staff did not notify authorized representative that client went to the hospital. The Department conducted staff interviews and reviewed documentation. Upon a review of Client One (C1’s) Emergency Notification file, information revealed that C1 had an emergency contact.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
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 6
Control Number 18-AS-20231009143347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MATTHIAS HOME
FACILITY NUMBER: 336426745
VISIT DATE: 12/04/2023
NARRATIVE
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However, interviews conducted revealed C1’s emergency contact person was not contacted to inform of C1’s whereabouts. Thus, the regulatory requirement was not met, and 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.

An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811 (confidential names list), LIC9099D, and Appeal Rights.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20231009143347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MATTHIAS HOME
FACILITY NUMBER: 336426745
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2023
Section Cited
CCR
80072(a)(4)
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Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (4) To be informed, and to have his/her authorized representative, if any, informed, by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency, and of information regarding confidentiality. This requirement was not met as evidenced by:
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Licensee agrees to conduct in-service training on the cited regulation with all staff, and provide proof of such by POC date.
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Based on record review, notification was not made to C1's authorized representative when C1 was transferred to the hospital. This is a potential personal rights violation for 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: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
10/09/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20231009143347

FACILITY NAME:MATTHIAS HOMEFACILITY NUMBER:
336426745
ADMINISTRATOR:ADILENE QUINTANILLAFACILITY TYPE:
735
ADDRESS:13801 MOUNTAIN TOP DRIVETELEPHONE:
(760) 671-7421
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY:6CENSUS: 5DATE:
12/04/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Alexis Parker, Lead StaffTIME COMPLETED:
09:56 AM
ALLEGATION(S):
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Due to lack of supervision, client got into an altercation with another client resulting in injury
Staff not providing client adequate hygiene
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Lead Staff Alexis Parker and informed them on the purpose of this visit. During this investigation, LPA conducted interviews with staff and clients; obtained supportive documentation for review to assist with determining the findings for the above noted allegation. The following was determined.

Allegation #1 - An allegation received stated that due to lack of supervision, Client #1 (C1) got into an altercation with Client #2 (C2) resulting in injury to C1. The evidence obtained through record review revealed that an incident occurred on 9/16/23,
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20231009143347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MATTHIAS HOME
FACILITY NUMBER: 336426745
VISIT DATE: 12/04/2023
NARRATIVE
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 in which C2 attempted to choke C1 several times, and was successful at hitting C1 twice in the head as witnessed by staff, this was confirmed through an interview statement. Staff interviews revealed that staff were able to diffuse the situation from escalating further, and ultimately assisted both clients to obtain treatment; medical, or otherwise by medical professionals. The Department then reviewed medical documentation regarding C1 and found that concluding C1’s hospital visit to Eisenhower Medical Hospital (EMH) on 9/16/23, C1 had a healed abrasion to their left eyebrow, a right nasal crease abrasion, and abrasions to their neck. Medical documentation further noted C1 did not appear to be in pain, and C1’s neurological exam came back normal. The hospital discharged C1 back to the facility with normal findings.

A separate incident was noted through record review, on 9/22/2023. Staff interview indicated that on 9/22/2023, C1 was displaying disruptive behaviors during the morning hours while at the facility such as, toppling their dresser and yelling at things not visible. Staff stated that C1 had not slept in a couple of days. Due to C1’s disruptive behaviors, a phone call was made to a medical facility, where the recommendation by a medical professional was to notify law enforcement. LPA reviewed Law Enforcement notes of the day of incident and found that Law Enforcement observed C1 throwing items, and trying to break the sliding door, while having a manic episode. Law Enforcement notes continued and revealed that law enforcement personnel requested medical aid for C1. Other records reviewed revealed C1 was treated at EMH due to being awake for a couple of days. Upon admission to EMH, records indicated that C1 was not in distress. Due to a possible medical condition, Hospital Staff made the decision to transfer C1 to Pacific Grove Hospital for an evaluation. According to documentation provided and reviewed at admission to Pacific Grove Hospital, C1 complained of knee pain, and was given a wheelchair, and deemed a fall risk. At that time, X-rays were taken of C1’s knees, and no injury was noted. Documentation further revealed that on 10/4/23, C1 was admitted to Riverside Community Hospital in relation to leg pain and after evaluation, was found to have a broken hip.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20231009143347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MATTHIAS HOME
FACILITY NUMBER: 336426745
VISIT DATE: 12/04/2023
NARRATIVE
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Of the evidence presented through interviews with staff, relevant sources, and documentation, C1 did not have any complaints of pain upon examination to Eisenhower Medical Hospital on 9/22/2023 after leaving the facility. Upon review of EMH records, there were no indications noted of ambulation concerns or pain. Based on record review, and interviews, the allegation was Unsubstantiated.

Allegation# 3 - Staff not providing client adequate hygiene. The Department’s investigation consisted of interviews with staff, relevant sources, and involved clients, as well as a review of records and documentation. Staff interview revealed that C1 has episodes where C1 will urinate on themselves 1-2 times per month. Multiple staff were interviewed, and all have corroborating statements that staff provide gentle reminders to C1 to shower. LPA reviewed showering logs provided by the facility, and the records revealed that C1 was provided shower reminders and showered as often as C1 desired. C1 confirmed receipt of showering through interview. Based on interviews with staff, and C1, and a review of documentation provided by the facility, this allegation was Unsubstantiated.

A finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where a copy of this report was discussed with and provided, along with a copy of the LIC811 (confidential names list).
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6