St Matthews Home for the Elderly

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Administrator, Silvia Castro.and explained the purpose of today's visit. Facility is licensed to serve six (6) non-ambulatory residents, age 60 and above, of which one (1) maybe bedridden. Annual licensing fee is current. Administrator certificate is current and the expiration date is 10/14/23. During the visit, CARE tool was used, a tour of the facility was conducted, food supply was reviewed, staff/resident files were reviewed, and medications were reviewed. The facility is a single story house located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. The facility consisted of 4 residents bedroom, 2 1/2 bathrooms, dining room, kitchen, TV/living room, and family room. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 106.1 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. Sufficient supply of perishable and nonperishable foods was observed. A dual device of smoke detectors combined with carbon monoxide detectors were tested and operable. Fire extinguishers’ last service was 03/18/23 and fully charged. Medication were centrally stored in a locked storage room and inaccessible to residents. Resident records were stored in a locked storage room and inaccessible to residents. No deficiencies were observed during the visit. An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Jul 20, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with staff, Reinalyn Martin, who assisted with the visit. LPA spoke with Administrator, Silvia Castro over the phone and explained the purpose of today's visit. Administrator joined the visit at around 4:30pm. Facility is licensed to serve six (6) non-ambulatory residents, age 60 and above, of which one (1) maybe bedridden. Annual licensing fee is current. Administrator certificate is current and the expiration date is 10/14/22. Facility has hospice waiver for two (2). Currently, four (4) hospice residents residing at the facility. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is a single story house located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. The facility consisted of 4 residents bedroom, 2 1/2 bathrooms, dining room, kitchen, TV/living room, and family room. Facility has a main entry point for screening. All four residents bedrooms were toured. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 112.1 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. No firearms on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. ( - continued in LIC 809 C-) Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. A dual device of Smoke detectors combined with carbon monoxide detectors are tested and operable. Fire extinguishers’ last service is 4/15/22 and are fully charged. The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked storage room and inaccessible to residents. Resident records are stored in a locked storage room and inaccessible to residents. Toxic substances are inaccessible to residents. Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D. An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents. A copy of appeal rights was provided.the state’s words, verbatim · CDSS document, Jun 10, 2022

Type of visit: POC

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Plan Of Correction (POC) visit to follow up on the deficiency issued during the 4/28/22 case management visit. Upon arriving at the facility, LPA met with Staff / Reinalyn Martin and was later joined by the Administrator / Silvia Castro who assisted with the visit. The purpose of this visit was explained. On 4/28/22 the facility was cited for: Personnel Requirements - General. Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by: During a complaint investigation conducted on 4/28/22, LPA discovered that individuals: Reinalyn Martin and Reginald Zaragosa have been working at the facility prior to requesting a transfer of a criminal record clearance. The Plan of Correction (POC) for this deficiency stated that the Administrator will ensure individuals: Reinalyn Martin and Reginald Zaragosa are associated to St Matthews Home for the Elderly and provide proof to CCL by the POC due date of 4/29/22. The Administrator failed to submit the POC to CCL by the POC due date of 4/29/22, therefore Civil Penalties are being issued for period 4/30/22 - 5/6/22. Total of 7 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $700. Civil penalties will continue to accrue until the POC is submitted to CCL. A deficiency is cited per California code of Regulations, Title 22, Division 6 LPA explained the citation, civil penalty assessment, and appeal rights. Exit interview was conducted and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 6, 2022

Allegation investigated: Staff not providing adequate service to residents in care.

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Reinalyn Martin who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Staff not providing adequate service to residents in care." During today's visit, LPA interviewed Staff members 1 and 2 (S1 and S2) and Residents 1 through 5 (R1 - R5). LPA was unable to interview Resident 6 (R6) as R6 was observed sleeping at the time of this visit. The investigation revealed the following; Allegation: Staff not providing adequate service to residents in care. The details of this allegation states that for the last couple of months, residents have not been bathed and diapers not being changed. (Please see LIC 9099C for additional information) Unsubstantiated Based on interviews conducted the statements obtained were inconsistent and did not corroborate with the allegation. Residents interviewed confirmed that residents are given a shower/bath three times a week and diapers are changed three times a day (morning, afternoon and before bedtime) or as needed. Statements obtained from staff corroborated with the statements obtained from residents. LPA learned that some residents receive baths from nurses from outside agencies and in the event that an outside agency nurse is not able to visit the facility, facility staff will proceed to give the resident(s) a bath. Based on the information gathered, there is insufficient evidence to support the allegation to be true. Although the allegation may have happened or is valid, there is not a 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, Apr 28, 2022 · control 28-AS-20220418144305

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. During a complaint investigation conducted on 4/28/22, LPA discovered that individuals: Reinalyn Martin and Reginald Zaragosa have been working at the facility prior to requesting a transfer of a criminal record clearance as specified in Section 87355(c). Also, individual: Orlando Placino has been working at the facility prior to obtaining a California clearance or a criminal record exemption as required by law or Department regulations. Reinalyn Martin has been working at St Matthews Home for the Elderly since 8/1/21. Reginald Zaragosa has been working at St Matthews Home for the Elderly for three days. Orlando Placino has been working at St Matthews Home for the Elderly since 12/3/21. Per Ms. Martin, LPA was told that the Administrator will associate herself and Reginald Zaragosa to St Matthews Home for the Elderly later today. Orlando Placino left the facility at the time of this visit and was asked not to return until he has obtained a California clearance or a criminal record exemption as required by law or Department regulations. The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D) An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.the state’s words, verbatim · CDSS document, Apr 28, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(2) · Plan of correction due date: Apr 29, 2022

Personnel Requirements - General. Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by: During a complaint investigation conducted on 4/28/22, LPA discovered that individuals: Reinalyn Martin and Reginald Zaragosa have been working at the facility prior to requesting a transfer of a criminal record clearancethe state’s words, verbatim · CDSS document, Apr 28, 2022

Plan of correction: Administrator will ensure individuals: Reinalyn Martin and Reginald Zaragosa are associated to St Matthews Home for the Elderly and provide proof to CCL by the POC due date. Civil Penalties were issued in the amount of $800.00

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(g)(1) · Plan of correction due date: Apr 28, 2022

Personnel Requirements - General. Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: Obtain a California clearance or a criminal record exemption as required by law or Department regulations. This requirement is not met as evidenced by: During a complaint investigation conducted on 4/28/22, LPA discovered that individual: Orlando Placino has been working at the facility prior to obtaining a California clearance or a criminal record exemption as required by law or Department regulations. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 28, 2022

Plan of correction: Individual Orlando Placino left the facility at the time of this visit and will not return until he has obtained a California clearance or a criminal record exemption as required by law or Department regulations. A Civil Penalty was issued in the amount of $500.00

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Linda Almaraz conducted an annual required visit at the facility above. LPA met with Caregiver, Maria Pelky and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications and observed food supply. Facility has submitted a mitigation plan and pending approval. The facility is a 4 bedroom, 3 bathroom (1 bathroom for staff/visitors) home located in a residential neighborhood. Facility has a main entry point for screening. All 6 residents bedrooms were toured. Each bedroom had required furniture and equipment. All bathrooms were toured and the toilets, hand washing and showers are safe and sanitary. Bathrooms had hand soap. The food in the kitchen was sufficient supply of 2 days perishable and 7 days non-perishable. The common areas such as living room and dining area are clean and have the required furniture. The backyard has a shaded area and sitting area. Medications are centrally stored, locked along with the records. Carbon monoxide and smoke alarm detectors were tested and working. Water temperature in both bathrooms were not within required range of 105-120 degree F. Bathroom #1 was reading at 129 degree F and bathroom #2 125 degree F. Deficiencies cited under California Code of Regulations Title 22 An exit Interview was conducted with the Administrator via telephone and a hardcopy was provided to the caregiver. Appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 11, 2021