198602923-4-29-2021-28-AS-LHIS-C6USTU-20210914141006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602923
Report Date: 04/29/2021
Date Signed: 04/29/2021 03:20:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210405154549

FACILITY NAME:	A FAITHFUL HOME OF CERRITOS		FACILITY NUMBER:	198602923
ADMINISTRATOR:	THANG DUC DUONG		FACILITY TYPE:	740
ADDRESS:	11213 AGNES ST		TELEPHONE:	(714) 300-8055
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY:	6	CENSUS: 6	DATE:	04/29/2021
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Theresa Kholoma, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Resident's diapering needs are not being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza initiated a subsequent complaint investigation to deliver findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was explained telephonically to Administrator Theresa Kholoma.

The investigation consisted of: On 4/14/21 staff (S1-S4), three (3) family/other persons, and residents (R1-R3) were interviewed. Due to cognitive impairment issues residents (R4- R6) were not interviewed. Two (2) virtual tele-inspections of the physical plant were conducted at 11:02 am -11:22 am, and at 1:30 pm -1:45 pm. NOTE: A twin bed and roll away bed were observed in the garage. Staff denied night shift staff sleep/live in the garage. The following documents were obtained: resident's Identification and Emergency Information/Face Sheet, admission agreements, physician reports, hospice contact information, incontinence care plan, plan of operation, LIC 500 Personnel Report, and LIC 9020 resident roster. On 4/20/21 & 4/2021 additional interviews were conducted with family (F3-F7). A tele-inspection of the garage area was conducted today at 9:27 am- 9:35 am.

See LIC 9099C for continuation

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210405154549

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/29/2021

NARRATIVE

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Allegation: "Resident's diapering needs are not being met." Based on information obtained from document review and interviews conducted the findings reveal that night shift staff are expected to change resident's diapers at 7:00 pm, 10:00 pm, 2:00 am, 5:00 am, and if needed in between hours. The day shift staff change the resident's diapers at 7:00 am, 12:00 pm, 5:00 pm, and in between hours as needed. Resident's bedtime is at 7:00 pm. Staff (S1- S4) denied not changing the resident diapers after the 7:00 pm diaper change until the next day at 6:00 am. Staff (S2) was interviewed and initially stated that it lives at the facility, but later denied sleeping during night shift hours and failing to meet the resident's nighttime diapering needs. A total of four (4) staff were interviewed, all denied knowledge of night shift staff sleeping during shift hours. The facility plan of operation states they have awake staff 24 hours a day. Observations made on 4/14/21 & today resulted in deficiencies under a case management visit.

Residents (R1-R3) did not report any issues with incontinence care, or knowledge that other resident's diapering needs are not being met. Residents (R4-R6) were not interviewed due to cognitive/communication disability. A total of seven (7) family members and/or authorized representatives of current and former residents were interviewed. None reported knowledge or observations of incontinence care issues or diaper change problems. The majority of the resident's receive day time family visits. Therefore, family members could not confirm diaper change negligence during night time hours. Administrator stated that there is one resident whose Foley catheter is changed every 2 hours. Staff gently wake up resident's in need of night time incontinence care so they could be comfortable throughout the night. Staff denied leaving residents soiled or wet during nighttime hours. Hospice residents are also assisted with diapering needs by hospice providers. Based on interviews conducted and information gathered there is insufficient evidence to prove the allegation.

The findings indicate that 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.

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 9099 reports and return to LPA.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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