<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602923
Report Date: 07/19/2022
Date Signed: 07/19/2022 01:14:28 PM


Document Has Been Signed on 07/19/2022 01:14 PM - It Cannot Be Edited

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:THERESA KHOLOMAFACILITY TYPE:
740
ADDRESS:11213 AGNES STTELEPHONE:
(714) 300-8055
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 5DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rudy Ignacio; House ManagerTIME COMPLETED:
01:21 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with House Manager Rudy Ignacio and explained the reason for the visit. Administrator Theresa Kholoma was informed of the visit via phone call. Physical Plant was toured, medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Mr. Ignacio toured the home and observed: (5) bedrooms, (2) bathrooms, living room, kitchen, dining room, and attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 in the hallway and measured at 119.4F which is within the required 105F - 120F degrees. Grab bars and non-skid mats were observed in the bathrooms. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector located in the hallway of the home. There is a fire extinguisher located near the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Cleaning supplies and disinfectants are locked under the sink and are inaccessible to the residents. First Aid kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Staff were observed wearing masks and screening visitors at entry.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • (4) out of the (5) resident medications were reviewed. Medications are centrally stored in a cabinet near the dining room. Medications are documented properly and given as prescribed.
  • Staff and Resident files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1