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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426745
Report Date: 07/22/2024
Date Signed: 07/22/2024 12:23:49 PM

Document Has Been Signed on 07/22/2024 12:23 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MATTHIAS HOMEFACILITY NUMBER:
336426745
ADMINISTRATOR/
DIRECTOR:		ADILENE QUINTANILLAFACILITY TYPE:
735
ADDRESS:13801 MOUNTAIN TOP DRIVETELEPHONE:
(760) 671-7421
CITY:DESERT HOT SPRINGSSTATE: CAZIP CODE:
92240
CAPACITY: 6CENSUS: 6DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Alexis ParkerTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 7/22/24 Licensing Program Analyst (LPA) Valerie Flores and Licensing Program Manager (LPM) Rikesha Stamps conducted an unannounced one (1) year required visit. LPA Flores and LPM Stamps were granted entry by staff member Shalayia Johnson, who was informed of the purpose of the visit. The Licensee/Administrator Alexis Parker was on site during the time of visit. At the time of the visit there were two (2) staff and two (2) residents present. All staff present were observed to have obtained proper fingerprint clearance and were associated to the facility. LPA observed the following during today's visit:

LPA Flores and LPM Stamps conducted a tour of the facility with staff Shalayia. Indoor and outdoor passageways were free of obstructions. There were no bodies of water observed. The facility meets the requirements of the two (2) day supply of perishable foods and seven (7) day supply of non-perishable foods. LPA Flores and LPM Stamps observed a additional refrigerators in the garage with perishable foods along with emergency food and water. Resident bedrooms had the required bedding, furniture, and lighting. Resident bathrooms had grab bars and non-skid mats in the showers. Disinfectants and cleaning solutions were secured in the locked laundry room The combined smoke and carbon monoxide detectors were tested and were observed to be operable. LPA Flores measured the water temperature at 118 Fahrenheit just meeting within the departments requirements. Medications were observed to be centrally stored in a locked cabinet located in the kitchen and inaccessible to the clients. Medication records were reviewed for clients in care, no discrepancies observed. LPA Flores and LPM Stamps reviewed random staff files and all resident files and found that Client 1 (C1) was missing a physicians report on file. Administrator file was reviewed and included a criminal record clearance and updated CPI training. Resident files reviewed included completed admission agreements. Facility sketch, License and Emergency disaster plan information is posted in the living room near the kitchen. LPA confirmed with staff there are no firearms or ammunition on the premises.



During today's visit, LPA Flores issued a deficiency. An exit interview was conducted with Administrator, and a copy of this report, LIC809-D, and appeal rights was reviewed and provided to Licensee.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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 07/22/2024 12:23 PM - It Cannot Be Edited


Created By: Valerie Flores On 07/22/2024 at 12:04 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: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on client record review, the licensee did not comply with the section cited above; one (1) out of six (6) clients physician report was not included in the clients file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Adminstrator Alexis Parker agreed to send physican report via email for C1 by 8/2/24.
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:Rikesha Stamps
LICENSING EVALUATOR NAME:Valerie Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
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