198602923-9-1-2023-28-AS-RORN-CW4Q5E-20230928115148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602923
Report Date: 09/01/2023
Date Signed: 09/01/2023 11:18:18 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
08/03/2023 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20230803131312

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:	09/01/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	House Manager Rudy Ignacio		TIME COMPLETED:	12:05 PM

ALLEGATION(S):

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Staff member physically abuses residents while in care.

INVESTIGATION FINDINGS:

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On 9/1/23 at 10:15 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to deliver findings. Upon arrival LPA met with Staff #1 (S1) and explained the reason for the visit. S1 contacted the Administrator (Teresa Kholoma) at 10:20 a.m. The House Manager (Rudy Ignacio) arrived at 10:35 a.m., and LPA explained the purpose of the visit.

During the initial visit LPA toured the facility with Administrator. LPA obtained resident roster and staff roster. LPA conducted file review and obtained copies of all resident’s emergency and identification paperwork. LPA also interviewed: Administrator and a total of two (2) staff who shall be referred to as S1 and S2. LPA interviewed a total of 2 residents who shall be referred to as: R1 and R2. Due to the Resident #3 through Resident #5 diagnosis LPA could not conduct interviews. LPA also interviewed Responsible party (RP) for R3 via phone. LPA attempted to interview Responsible Parties for residents R4 and R5 twice and left a message.

Report continued on 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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-20230803131312

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: 09/01/2023

NARRATIVE

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Prior to the visit LPA interviewed RP for resident #4. During todays visit LPA conducted exit interview.

The investigation reveals the following: Regarding "Staff member physically abuses residents while in care.”. It is alleged that staff S1 pushed and grabbed a resident by the ear. During the visit LPA interviewed the administrator. The Administrator denied the allegation stating staff has never hit the residents. The administrator further stated that this is the first time the facility has heard of the allegation. 2 out of 2 staff denied the allegation, stating they have never hit any of the residents. 3 out of 3 residents denied the allegation, stating staff has never hit them and they have not witness staff hitting another resident. 2 out of 2 RP denied the allegation stating they have never witnessed physical abuse at the facility.

Based on LPA's interviews, investigation revealed: 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.

Exit interview conducted with Rudy Ignacio and a copy of this record provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC9099 (FAS) - (06/04)

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