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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426745
Report Date: 09/23/2022
Date Signed: 09/23/2022 02:01:17 PM

Document Has Been Signed on 09/23/2022 02:01 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:ERICKA MUNOZFACILITY TYPE:
735
ADDRESS:13801 MOUNTAIN TOP DRIVETELEPHONE:
(760) 671-7421
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY: 6CENSUS: 5DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:James Toland - House ManagerTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with House Manager James Toland and advised them of the purpose of the visit, and that the Annual Inspection will be focused on Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with House Manager James Toland, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to be sufficient for a 30-day supply. LPA Colvin went over the various recommended training for facility staff with House Manager James Toland in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and House Manager James Toland confirmed that they have conducted fit testing for all staff. LPA Colvin was informed that all but one staff have been vaccinated, and the one vaccinated staff member COVID tests weekly. In addition to going over the facility's policy for testing staff and residents for COVID-19, LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. House Manager James Toland confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility. LPA Colvin additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 09/23/2022
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Throughout LPA Colvin's inspection, LPA Colvin observed that both staff present were not wearing a face covering of any kind. LPA Colvin informed House Manager James Toland that at this time, Long Term Care Facilities (such as this facility) are still advised to have all staff and visitors wear a face covering at all times when inside the facility. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note at this time.

Other: LPA Colvin observed construction underway in the left wing of the facility, including exposed wood beams. LPA Colvin inquired about the construction, and House Manager James Toland informed LPA Colvin that they are working on adding two bedrooms to the facility, but that there are technicalities with dimensions that are holding things up. LPA Colvin observed permits and notices from the city on the door to the room with construction. LPA Colvin did not observe anything documented on Community Care Licensing's (CCL) side noting that CCL was made aware of the construction, but it is possible that CCL was notified and it was not memorized digitally. LPA Colvin recommends for the facility to add a letter or printed email to the documents on the door of the room with construction, to confirm that CCL was notified of the changes to the facility. Additionally, LPA Colvin observed numerous areas of the facility in poor condition/repair, such as the carpet in the main common areas of the facility (stained, holes, uneven patches) and the perimeter fence (missing planks or planks hanging off). LPA Colvin will be issuing a deficiency for this to ensure corrections are made for the betterment of the facility. Deficiency cited.

Based on observations made by LPA Colvin, the facility was cited and an exit interview was conducted with House Manager James Toland were a copy of this report, LIC809D, and appeal rights was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2022 02:01 PM - It Cannot Be Edited


Created By: Crystal Colvin On 09/23/2022 at 01:47 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: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two areas/aspects of the facility, which poses a personal rights risk to persons in care. LPA Colvin observed carpet in main common areas to be heavily stained and missing pieces or uneven in areas. LPA Colvin additionally observed wooden gate around facility to be missing planks of wood or having planks falling off.
POC Due Date: 10/14/2022
Plan of Correction
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Licensee agrees to fix noted areas and provide LPA Colvin with photographs of corrections. Photographs due by Plan of Correction date of 10/14/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022


LIC809 (FAS) - (06/04)
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