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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602923
Report Date: 04/29/2021
Date Signed: 04/29/2021 03:07:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A FAITHFUL HOME OF CERRITOSFACILITY NUMBER:
198602923
ADMINISTRATOR:THANG DUC DUONGFACILITY TYPE:
740
ADDRESS:11213 AGNES STTELEPHONE:
(714) 300-8055
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 6DATE:
04/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Theresa Kholoma, AdministratorTIME COMPLETED:
01:50 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Noemi Galarza conducted a Case Management-Deficiencies visit as a result of observations made while conducting complaint investigation control #: 28-AS-20210405154549. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s meeting was conducted telephonically with Administrator/Licensee Theresa Kholoma. Staff (S2) assisted with today's virtual physical plant tele-inspection.

Based on observations during two virtual physical plant inspections conducted while investigating an unrelated complaint on dates 4/14/21 at 11:02 am - 11:22 am & 1:30 pm - 1:45 pm, and today 4/29/21 at 9:27 am- 9:35 am two beds were observed in the attached garage. Both beds had linens, pillows, and a night stand dresser with staff personal belongings. Male staff clothing was observed hanging above the beds. On 4/14/21 during a complaint tele-inspection both Administrator and staff (S2) said the beds were placed in the garage because 2 residents required hospital beds. The regular room beds were moved to the garage for storage. However, caregiver staff (S2) was interviewed and confirmed "I sleep and take rests there." Staff (S2) stated the beds are also used by other caregivers as for nap time. Pictures were taken during the physical plant inspections. NOTE: pre-licensing report states room #5 is designated as a live-in staff room, but it is presently being used by a resident.



Administrator and staff (S2) stated there is only one staff scheduled to work during the night shift that is responsible for night supervision. Per facility plan of operation "Dementia Care Plan of Operation" page 7, "At least one staff member will be awake and on duty at night, if required, based on wandering or other similar risks."
Currently a total of three (3) residents in the home have a Dementia diagnosis.

Per Title 22, Division 6, Chapter 8, Article 12, 87705(c)(4)(A) Care of Persons with Dementia. In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. Based on observations deficiency is being cited. See LIC 809D.

A telephonic exit interview was conducted with Administrator Theresa Kholoma. A hard copy of the report was emailed. Staff was instructed to sign the LIC 809/LIC 809D report pages and return to LPA.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A FAITHFUL HOME OF CERRITOS
FACILITY NUMBER: 198602923
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2021
Section Cited

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87705(c)(4)(A ) Care of Persons with Dementia.( A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.
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Based on observations on dates 4/14/21 & today LPA observed 2 beds in the garage with linens, as well as personal staff items/clothing. Staff (S2) acknowledged sleeping/resting in the bed. S2 occasionally works alone during night hours. Pictures were taken. NOTE: Per pre-licensing visit room #5 was designated as a live-in staff room. However, it is presently being used by a resident.
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Type B
05/06/2021
Section Cited

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87307(a) Personal Accommodations and Services. Living accommodations and grounds shall be related to the facility's function. The facility .... provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.


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On 4/14/21 bedroom # 5 was observed to be used by resident. On the facility sketch it is listed as a live-in staff room. During tele-inspections on 4/14/21 & today 2 beds were observed in the garage that are being used by live-in staff. Staff (S2) confirmed that they are used facility caregiver staff.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2021
LIC809 (FAS) - (06/04)
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