St Matthew's Home for the Elderly IV

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Barbara Boiston, the House manager and 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. Six (6) approved hospice waivers and Dementia Care Program are in place. The facility is a single-family home located in a residential area in Glendora. It consists of four (4) resident bedrooms, two and a half (2 1/2) bathrooms, a TV room, living room, dining area, kitchen, attached garage, front yard, backyard 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 toured and in compliance. The outdoor and passageways were free of obstruction and hazards. Cleaning solutions, toxins, knives, and hazardous items were kept in a locked storage. They were inaccessible to residents. Water temperature was tested and the temperatures were between 112.5 to 115.7 degrees F., which is in compliance with regulations. 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. (-Continued on the LIC809-C) Operational Requirements and Disaster Preparedness: Facility has an activity area furnished for outdoor use. Fire drills were conducted quarterly and the last fire drill was on 8/9/26. 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 04/08/2027. 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: Two (2) days of perishables and one-week (7) days of non-perishables food supply were observed. The kitchen was observed to be clean. 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

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Blanca Gonzalez and Nune Margaryan conducted an announced Pre-Licensing Inspection visit and met with Applicant Terry McGee. This Pre-Licensing Inspection is due to a change of ownership. The facility has an approved fire clearance to be licensed to serve six (6) non-ambulatory clients. 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 with a separate back house, located in a residential area of Glendora consisting of common area with a TV, living room, dining area, kitchen, four (4) bedrooms, three (3) bathrooms, attached garage, front yard and back yard. Laundry area observed in the hallway included a locked cabinet for detergent and cleaning supplies. Fire smoke alarms and carbon monoxide detector observed, tested and are operable. The fire extinguisher observed and charged. continued on LIC809C Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Additional food supplies observed in the garage. Sharps were observed secured and inaccessible to residents. Medication is centrally located in a locked kitchen cabinet. Dining area was clean with sufficient seating. Living room was observed with sufficient seating for residents and a fireplace with a covered screen. Cameras were observed in facility common areas. Grab bars and non-skid mats were observed in the bathrooms. The water temperature was tested in all bathrooms and measured within the required 105-120 degrees F. Residents bedrooms have all required furniture, lighting, and bedding. There is closet space for clothing and other belongings. Extra clean linen were observed in an armoire located in the hallway. Staff and client files are maintained locked in a cabinet located in the kitchen. All cleaning solutions and disinfectants were observed locked under the kitchen sink. 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 umbrella for shade and sufficient seating for 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 was observed and is kept in the garage. The Pre-licensing is complete, and the facility has no deficiencies. Comp III was not conducted due to Applicant being a licensee and having other facilities. Exit interview conducted 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 14, 2025

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 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