198602923-11-22-2024-28-AS-RORN-DBMRZ2-20241204122711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602923
Report Date: 11/22/2024
Date Signed: 11/22/2024 01:46:15 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
09/19/2024 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240919114357

FACILITY NAME:	A FAITHFUL HOME OF CERRITOS		FACILITY NUMBER:	198602923
ADMINISTRATOR:	THERESA KHOLOMA		FACILITY TYPE:	740
ADDRESS:	11213 AGNES ST		TELEPHONE:	(714) 300-8055
CITY:	CERRITOS	STATE: CA	ZIP CODE:	90703
CAPACITY:	6	CENSUS: 6	DATE:	11/22/2024
		UNANNOUNCED	TIME BEGAN:	11:53 AM
MET WITH:	Rudy Ignacio - House Manager		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility roof is leaking.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent visit to deliver finding on the allegation listed above.Upon arrival LPA met with the House Manager Rudy Ignacio and explained the reason for the visit.

The investigation consisted of the following:
LPA Truman conducted initial visit on 9/24/24 during visit LPA toured the facility, requested a copy of the resident roster and staff roster via email, interviewed: 3 staff (S1-S3) and interviewed 3 residents (R1-R3).
During visit conducted on 11/12/24 LPA Herrera toured the facility, interviewed 3 staff (S1-S3), interviewed 3 residents (R1-R3) and 1 residents family memeber. LPA reviewed files for R1 and obtaineed copies of their Admission Agreement, Face Sheet and Physician Report and requested for Administrator Teresa to email LPA copy of rent increase letter for R1 and roof inspecion report.
(Continued on LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

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-20240919114357

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A FAITHFUL HOME OF CERRITOS	FACILITY NUMBER: 198602923
	VISIT DATE: 11/22/2024

NARRATIVE

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Allegation: Facility roof is leaking.
It is alleged that the roof in R1’s room has a leak in the ceiling. LPA toured R1’s room and observed a large bubble on the ceiling of R1’s room which usually indicates some sort of water damage. LPA interviewed 3 residents and 2 out of 3 confirmed that they have observed the leaks in R1’s room during the rainy season. LPA interviewed R4’s family member and they stated they have also witnessed the leak during the last rainy season. LPA interviewed 3 staff and 2 out of 3 staff confirmed that during the rainy season there had been a leak in the room of R1. Administrator Theresa stated that the facility has had a roof inspection done in which it was determined that the ceiling had no leaks. A copy of roof inspection dated 11/14/24 was provided to LPA via email by Administrator and it stated that there were no holes or openings seen in the attic area of the facility, however, there was no mention to the bubbling area on the ceiling of R1’s room.

Based on LPA's observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC9099-D.

Exit interview held, and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240919114357

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 11/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 12/09/2024 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator/Licensee to have a repair person who is knowledgeable in water damage and mold to inspect ceiling in R1's room. Copy of the inspection and any needed repairs to be provided and completed by POC due date.
	8 9 10 11 12 13 14	During visit on 11/12/24 LPA toured R1's room and observed a large bubble in the ceiling of R1's room. 2 staff confirmed there had been a leak in room during rainy season, 2 residents also confirmed leak, R4's family member also confirmed leak. Although Administrator provided a roofing inspection that was conducted 11/14/24, this roof inspection did not disclose inspection of the noticeable bubble in ceiling of R1's bedroom. During visit on 11/22/24 LPA observed bubble on ceiling of R1's room still present, and new damage to R1's recess lighting.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC9099 (FAS) - (06/04)

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