198602923-3-4-2024-28-AS-LHIS-D49LF7-20240412084237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602923
Report Date: 03/04/2024
Date Signed: 03/04/2024 02:36:23 PM

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
02/14/2024 and conducted by Evaluator Jewel Baptiste

COMPLAINT CONTROL NUMBER: 28-AS-20240214130214

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:	03/04/2024
		UNANNOUNCED	TIME BEGAN:	10:24 AM
MET WITH:	House Manager Rudy Ignacio		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not meet resident’s care needs in a timely manner.
Staff spoke in an inappropriate manner to resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 3/4/24 at 10:24 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). The house manager (Rudy Ignacio) arrived at 11:30 a.m., and LPA explained the purpose of the visit.

During visit on 2/20/2024, LPA toured the facility with Administrator. LPA requested resident roster and staff roster via email. LPA conducted file review and obtained copies of all resident’s emergency and identification paperwork and R1’s physician report via email. LPA conducted file review for S1. LPA also conducted file review for S1. LPA interviewed: Administrator and a total of two (2) staff who shall be referred to as S1 and S2. LPA interviewed a total of 3 residents who shall be referred to as: R1 through R3. Due to Resident #4 through Resident #6 diagnosis LPA could not conduct interviews.

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: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

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 2

Control Number 28-AS-20240214130214

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: 03/04/2024

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
26
27
28
29
30
31
32

Prior to the visit LPA conducted interviews with R4 and R5 responsible parties and shall be referred to as Witness #1 (W1) and witness #2 (W2). LPA attempted to contact R6 responsible party three times and left a voice mail.

The investigation reveals the following: Regarding " Staff did not meet resident’s care needs in a timely manner”. It is alleged that staff S1 takes 1 ½ to 2 hours to respond to R1’s calls. During the visit LPA interviewed the administrator. The Administrator denied the allegation stating staff has responded to all residents’ calls in a timely manner. 2 out of 2 staff denied the allegation, stating they have always responded in a timely manner, and it takes them no more than 20 minutes. They further stated there are times the residents want them to come right away, and they are bathing another resident. 2 out of 3 residents denied the allegation, stating staff have always responded when they are called at a reasonable time frame. 1 out of 3 residents stated S1 complains when called, but since residents have a call button staff has responded timely. 2 out of 2 witnesses stated they have not observed staff not responding to residents when they are at the facility.

The investigation reveals the following: Regarding " Staff spoke in an inappropriate manner to resident”. It is alleged that staff S1 complains about R1 taking too long to use the restroom. During the visit LPA interviewed the administrator. The Administrator denied the allegation stating that S1 is kind and have no issues. 2 out of 2 staff denied the allegation, stating they have always spoke appropriately to the residents. 2 out of 3 residents denied the allegation, stating staff has always treated them kindly. 1 out of 3 residents stated S1 complains when called and don’t like being rushed to use the restroom. 2 out of 2 witnesses stated they have not observed staff speaking inappropriately to the residents.

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 Teresa Kholoma 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: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2