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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408856
Report Date: 08/24/2021
Date Signed: 08/24/2021 03:57:30 PM

Document Has Been Signed on 08/24/2021 03:57 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:MATTHEWS COMFORT HOMEFACILITY NUMBER:
366408856
ADMINISTRATOR:DETOUCHE, MELIDAFACILITY TYPE:
735
ADDRESS:14594 WILLOW WAYTELEPHONE:
(760) 246-4425
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 1DATE:
08/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Melida De ToucheTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility. LPA arrived at the facility in order to conduct a case management visit to follow up on a client death. LPA met with Administrator, Melida De Touche, and explained the purpose of today's visit.

The case management visit consisted of collecting pertinent documentation and conducting staff interviews in regards to the death of Client #1 (C1). LPA interviewed Staff #1 (S1) and Staff #2 (S2) for further information in regards to the death of C1 and the events that led up to C1's death. S1 stated that the facility did not receive an official death certificate for C1; however, S1 and S2 stated that the preliminary cause of death is believed to be natural, stemming from C1's kidney disease. S1 and S2 stated that facility staff observed that C1 experienced a change of condition and took C1 to the hospital on 6/14/2021. C1 stayed in the hospital for 30+ days. C1 ultimately passed at the hospital on 7/23/2021. LPA has advised the Administrator to send a copy of the death certificate to the Department.

No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the Administrator.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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