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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408856
Report Date: 10/06/2023
Date Signed: 10/06/2023 12:01:23 PM

Document Has Been Signed on 10/06/2023 12:01 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
, 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: 2DATE:
10/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Sonya Braithhwaite, CaregiverTIME COMPLETED:
12:06 PM
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to complete a comprehensive annual inspection. LPA Nickolas met caregiver Sonya Braithwaite and explained the purpose of the visit. Today’s inspection included a facility tour, record review, and interviews with staff.

The facility is four (4) bedrooms and two (2) bathrooms of which three (3) bedrooms and one (1) bathroom are used for residents in care. The facility also has living room, dining area, covered patio, and attached garage. Licensed capacity is four (4), with a current census of two (2) residents in care.

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility temperature is 72 degrees Fahrenheit. LPA inspected resident bedrooms; each room included required furniture such as mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were functional. LPA Nickolas' observed adequate furniture and lighting throughout the facility. The hot water temperature tested within regulation at 105-116 Fahrenheit. The facility has operating smoke and carbon monoxide detectors, which LPA Nickolas tested during the visit. The facility has a charged fire extinguisher that is serviced by Hi Desert Fire. LPA Nickolas observed a personal rights poster, hand washing poster, and emergency contact information posted throughout the facility . LPA Nickolas observed that cleaning supplies, toxins, sharps, and other dangerous items are kept secure and inaccessible to residents in care. There was a designated storage space for client/staff files. LPA Nickolas observed medications locked and inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.



Food Service: Non-perishable and perishable food supply is sufficient in number for residents in care. The facility has a variety of food available for clients. Dishes, cups, and utensils were also appropriately stored.

Care & Supervision: The facility staff is sufficient in number for the care and supervision of residents in care. All staff members working in the facility have criminal record clearance through the department.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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
, CA 92507
FACILITY NAME: MATTHEWS COMFORT HOME
FACILITY NUMBER: 366408856
VISIT DATE: 10/06/2023
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Record Review: LPA Nickolas reviewed two (2) resident files for admission agreements, updated physician reports, and needs and services plans. Medications were audited randomly and appeared to be dispensed appropriately by staff members. LPA Nickolas reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

LPA Nickolas' issued three (3) technical violations (LIC 9102TV) during today's visit. An exit interview was conducted where a copy of this report and LIC 9102TV were discussed and provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC809 (FAS) - (06/04)
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