ST MATTHEWS HOME FOR THE ELDERLY

Official classification

Type B

Official code

87633(j)(1)

Regulation authority

CCR

What the official deficiency says

(j) A written health condition exception request and approval from the Department in accordance with Section 87616, is not needed for any restricted health conditions listed in Section 87612, Restricted Health Conditions, or for any prohibited health conditions listed in Section 87615, Prohibited Health Conditions, provided the resident or prospective resident has been diagnosed as terminally ill and is currently receiving hospice care, in compliance with Section 87633, Hospice Care for Terminally Ill Residents, and the treatment of the restricted and/or prohibited health conditions is addressed in the hospice care plan. (1) In caring for a resident's health condition, facility staff, other than appropriately skilled health professionals, shall not perform any health care procedure that under law may only be performed by an appropriately skilled professional. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above, as R4 shared a bedroom with another resident while receiving hospice services, and a signed agreement consenting to the shared room arrangement was not available for review, which posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/18/2026 Plan of Correction Licensee shall obtain and maintain a signed agreement from R4, or the resident’s authorized representative, consenting to the shared bedroom arrangement while roommate is receiving hospice services. Licensee shall submit a copy of the signed agreement to CCL.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in one (1) out of five (5) residents reviewed, as R4 did not have a physician’s order for bed rails, which posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/18/2026 Plan of Correction Administrator to obtain and submit a physicians order for R4's bedrails by POC due date.

Official classification

Type B

Official code

87156(a)(F)

Regulation authority

CCR

What the official deficiency says

87156(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. (F) A late fee that represents an additional 50 percent of the established annual fee when any licensee fails to pay the annual licensing fee on or before the due date as indicated by postmark on the payment. This requirement is not met as evidenced by: Based on record review, Licensee has failed to submit the required facility annual fees, resulting in noncompliance.

Official plan of correction

Licensee will submit the required facility annual fees to the Department by 12/25/25. Licensee will ensure all future annual fees are paid by the required due date to maintain compliance.

Deadline recorded: Dec 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87606(c)

Regulation authority

CCR

What the official deficiency says

(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/24/2025 Plan of Correction Administartor will speak to family, relocate resident and email LPA plan by POC due date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above R4 did not have TB, R5 was missing completed 602 with TB, And R1 was missing admission agreement, conset forms, appraisel needs and service, and emergency identification form which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2025 Plan of Correction Administartor will send all required documents by POC due date.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above R5 did not have orders for bedrails which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2025 Plan of Correction Administrator will send orders for bedrails by POC due date.

Official classification

Type B

Official code

87632(a)

Regulation authority

CCR

What the official deficiency says

Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. This requirement is not met as evidenced by: Facility has approved of two (2) hospice waivers. Currently, facility has four (4) residents on hospice residing at the facility. Administrator did not apply hospice increase request to Licensing to apply for 2 more hospice waviers. Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above regulation which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/17/2022 Plan of Correction Administrator will submit a request to Licensing and related documents to apply for hospice waiver requests by POC date. 

Official classification

Type A

Official code

87411(g)(2)

Regulation authority

CCR

What the official deficiency says

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

Official 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

Deadline recorded: Apr 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(g)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official 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

Deadline recorded: Apr 28, 2022. A deadline is not proof that correction was completed.