198602923-10-5-2022-28-AS-RORN-CJXUXC-20221006155808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602923
Report Date: 10/05/2022
Date Signed: 10/05/2022 11:38:36 AM

Unsubstantiated

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
04/01/2021 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210401123043

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:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Staff #2 (S2: Amelia Morales, 2nd House Manager).		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not refill resident's medication.
Staff are not scheduling resident's medical appointments.
Staff are not ensuring resident has transportation to medical appointments.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1: Donold Daca, Lead Caregiver; as Administrator, Theresa Kholoma was unavailable at the time of this visit. LPA/RA spoke to S1 prior to entering the facility to conduct a risk assessment. S1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation(s). An initial 10-Day virtual visit was conducted by LPA Angelica Rea on 04/08/21 (via telephone) with Administrator (A1: Theresa Kholoma) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

LPA/RA Ceniceros interviewed (between 8:30 a.m. - 10:00 a.m.) three (3) staff members, two (2) witnesses, and Resident #1 was not interviewed; as the resident moved out of the facility on 12/12/21. LPA/RA reviewed (between 10:00 a.m. – 10:45 a.m.) the requested documentation: Resident #1's Emergency I.D. & Information (dated 03/15/21), Admission Agreement (dated 03/15/21), Physician's Report (dated 03/20/21),

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20210401123043

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: 10/05/2022

NARRATIVE

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Pre-Placement Appraisal (dated 03/15/21), Appraisal Needs & Services (dated 05/20/21), Medication Administration Record - MAR (March 2021), and Memorial Care Home Health Agency Certification Period, effective 11/20/20 - 01/20/21.

Regarding Allegation #1: this investigation revealed based on interviews conducted, the majority corroborated that there was a lack of communication between the skilled-nursing facility and the assisted-living facility when Resident #1 (R1) had transferred to the facility on 03/15/21. Complainant misunderstood and thought Resident #1 was out of prescription medications (Levothyroxine & Allopurinol) altogether; however, later learned that the resident had a few meds to hold over a few days. Once the physician's authorization was established with the pharmacy, Resident #1 was back on their routine medications.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of MEDICATION: Staff did not refill resident's medication is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on interviews conducted, the majority corroborated that Witness #2 would schedule Resident #1's medical appointments; although, Resident #1 was already receiving home health care. Administrator did take over to schedule the resident's medical appointments from Witness #2; of which, Witness #1 confirmed that Resident #1 had been scheduled for and attended medical appointment(s) with the primary care physician.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Staff are not scheduling resident's medical appointments is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed based on interviews conducted, the majority corroborated initially Resident #1 could not get transportation services every other day from Cerritos to Buena Park for the resident's medical appointments. Once Witness #2 located a new dialysis center (around the corner from the facility), transportation arrangements were made (through the city's dial-a-ride); and, the Administrator took over from Witness #2 and began making the resident's transportation to their medical appointments.

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210401123043

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: 10/05/2022

NARRATIVE

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Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Staff are not ensuring resident has transportation to medical appointments is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Staff #2 (S2: Amelia Morales, 2nd House Manager).

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

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