St Matthew's Home for the Elderly V

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual visit at the facility using the CARE inspection tool. Upon arrival, LPA met with Barbara Boiston, the House manager. The reason for the visit was explained. The facility is licensed as a Residential Care for Elderly (RCFE) to serve six (6) non- ambulatory residents who are 60 years old and above. The facility has six (6) approved hospice waivers and Dementia Care Program in place. The facility is a single-family home located in a residential area in Glendora. The facility consists of a living room, dining room, kitchen with a medication cabinet, three (3) residents bedrooms, two (2) bathrooms, and back yard with shaded area and patio furniture. The following CARE tool domains were reviewed during this visit: Infection Control: Sufficient PPE supplies and an Infection Control Plan maintained at the facility were observed and in compliance. Physical Plant & Environment Safety: Physical plant tour was conducted. Residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The outdoor and passageways were free of obstruction and debris/hazards. Storage areas for cleaning solutions, toxins, knives, and hazardous items were kept in a locked cabinet and were inaccessible to residents. Water temperature was tested and the temperatures were between 118.1 to 119.5 degrees F., which is in compliance with regulations. (-Continued on the LIC809-C) Smoke detectors and carbon monoxide detectors were checked and operable. Fire extinguishers were observed and fully charged. Audio devices on the exit doors were operable. Operational Requirements and Disaster Preparedness: Facility has an activity area furnished for outdoor use. Fire drills were conducted quarterly. The last fire drill was on 08/09/2026. Annual fees are current. Staffing and Personnel Records- Training: There appears to be sufficient staffing at all times in the facility. Staff files were reviewed and in compliance. Administrator certificate is current with the expiration date on 09/08/2027. Resident Rights-Information and resident Records-Incident Reports: Facility provided telephone landline and internet for the residents. Resident rights posters and reporting posters were displayed within the facility. Food Service: The kitchen was observed to be clean. Two (2) days of perishables and one-week (7) days of non-perishables food supply were observed. Health Related Service: Medication was properly labeled, centrally stored, and in their original containers. Incidental Medical & Dental and Emergency Intervention: Staff designated to administer medication have the proper training on file. Residents at this facility do not need the use of restraints or de-escalation techniques, however, staff maintain a CPI Certificate in the case of use. Exit: Deficiencies were noted per California Code of Regulations, Title 22, Division 6 during this visit. Exit interview was conducted with Barbara Boiston, the House manager. Copies of LIC 809s and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 22, 2026

Allegation investigated: Staff do not allow resident to go outside of facility

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced initial 10-day complaint investigation visit regarding the above allegation. LPA Gonzalez was greeted by staff, and the purpose of the visit was explained. House Manager Barbara Boiston arrived shortly after. The investigation consisted of the following: LPA Gonzalez requested copies of Personnel Roster, Resident Roster, and the following documents for R1: Admission Agreement, physician’s report, Resident Pre-Appraisal, Functional needs and service plan. LPA toured the facility physical plant tour, interviewed staff #1-3 (S1- S3) and interviewed residents #1-3 (R1-R3). continued on LIC9099C Unsubstantiated Regarding allegation “Staff do not allow resident to go outside of facility.” It was reported that R1 asked to go outside the last few days and staff did not allow R1 to go outside. The investigation revealed 3 out of 3 staff deny the allegation. S3 stated R1 was asked by staff to wait, as staff had been assisting other residents, before S3 walked outside with R1. S1 and S2 stated they will walk outside with R1 a couple of times a day. Interviews with residents revealed 2 out of 3 residents interviewed stated staff do not deny residents requests to go outside, staff are great and staff are helpful. Residents are not denied stepping outside if they want. R1 stated S1 did not let R1 go outside but could not confirm when nor number of times R1 was not allowed outside by S1. Based on interviews, record review and observations, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 28-AS-20260130151913

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Blanca Gonzalez conducted a Case Management Visit-Deficiencies stemming from initial complaint investigation conducted on 02/05/2026, complaint control # 28-AS-20260130151913. LPA Gonzalez met with House Manager Barbara Boiston and explained the reason for visit. Case Management-Deficiencies findings: During complaint investigation dated 02/05/2026 LPA observed the following: LPA Gonzalez conducted a record review of R1’s file and observed the file did not contain a medical assessment for the resident. Staff was not able to produce the medical assessment at the time of the visit. Deficiency is being cited. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided to House Manager Barbara Boiston.the state’s words, verbatim · CDSS document, Feb 5, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(10) · Plan of correction due date: Feb 26, 2026

87506(b)(10)Resident Records Each resident’s record shall contain at least the following information: Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions. This requirement is not met as evidenced by: Based on record review and interview, facility file for R1 did not contain a medical assessment for the resident and staff was not able to produce the medical assessment at the time of visit.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: House manager agrees to submit to LPA via email a completed medical assessment for R1 by POC due date.

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Blanca Gonzalez and Mary Flores conducted an announced Pre-Licensing Inspection visit and met with Applicant Terry McGee and Barbara Boiston, House Manager. The facility has an approved fire clearance to be licensed to serve six (6) non-ambulatory residents ages 60 and above. LPAs and applicant toured the physical plant interior and exterior. The Pre-Licensing Inspection CARE Tool was used. The following was observed/inspected: The facility is a single-story home located in a residential area of Glendora consisting of a living room, dining area, kitchen, three (3) bedrooms, two (2) bathrooms. The home is located behind a current licensed facility in the same property. They will not be sharing staff or food preparation as each will prepare their own meals. Laundry area observed in the hallway included a cabinet for extra towels and linens. Fire smoke alarms and carbon monoxide detectors observed, tested and are operable. The fire extinguishers observed and charged. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. Sharps were observed secured in a locked kitchen cabinet, inaccessible to residents. (CONTINUED ON LIC 809C) Medication will be centrally located in a locked kitchen cabinet, inaccessible to residents in care.Staff and client files will be maintained locked in a cabinet located in the kitchen. Dining area was clean with sufficient seating for six (6) residents. Living room was observed with sufficient seating for six (6) residents. Applicant will ensure that there is a comfortable moving/walking area in between the dining area and the living area. Grab bars and non-skid mats were observed in bathrooms. The water temperature was tested between 114.5 and 118.5 in both bathrooms and it is within the required 105-120 degrees F. Residents’ bedrooms have all require furniture which includes, for each resident, a chair, nightstand, a lamp, or lights sufficient for reading. Bed linens were clean and in good repair. There is a closet space for clothing and other belongings All cleaning solutions and disinfectants were observed locked under the kitchen sink and kitchen cabinet. Doors, exits, hallways, and passageways were clear and free of obstruction. The front and back yards were observed to be clean and free of debris. There is an outdoor seating area with an umbrella for shade and sufficient seating residents. No pools or bodies of water were observed in or around the home. There are no firearms present at the facility. The first-aid kit has required items, and a current manual was observed and is kept in the kitchen. The Pre-licensing is completed. Applicant will send pictures of required posters posted as they were available but not posted and an additional grab bar in bathroom #2 as there was one grab bar in the shower and there was not one on the side of the shower. Once that is completed the physical plant meets Title 22 Regulations. Comp III was not conducted as the Applicant being is a licensee and has other facilities. Exit interview was conducted with applicant Terry McGee and a copy of this report was provided to Applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Office

Facility Type: RCFE Application Type: initial Capacity: 6 Census (if any clients in care): N/A COMP II Participants: licensee/administrator Terry McGee Interview Method: Telephone interview On 7/10/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jul 10, 2025