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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602923
Report Date: 06/24/2024
Date Signed: 06/24/2024 02:23:22 PM


Document Has Been Signed on 06/24/2024 02:23 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: 6DATE:
06/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Manager Rudy IgnacioTIME COMPLETED:
02:40 PM
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On 6/24/24 at 8:40 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to A Faithful Home of Cerritos. Upon arrival LPA was greeted by Direct Support Professional (DSP) Mark Anthony who contacted the House Manager, Rudy Ignacio. At 8:50 a.m. to assist with today's visit. This home is licensed to serve age range 60 and over. Six (6) non-ambulatory only. Hospice waiver for two (2). There were (6) residents in care during the time of this visit. The last emergency disaster/fire drill was conducted on 5/24/2024. The Administrator Certificate expires on 4/28/2025 #6034678740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (4) staff files, (6) resident files, and medications for (6) residents. LPA attempted to interview all 6 residents, 2 of which was able to communicate. LPA also spoke to a responsible party for 1 of the residents. During the visit 2 staff was interviewed.

This home contains 5 bedrooms, 2 bathrooms, living room with non-working fireplace, kitchen, dining room and an attached garage. LPA toured the physical plant with the House Manager and observed all (5) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 119.6*F-120.0*F. The smoke detectors were battery operated, tested, and observed to be working properly. The carbon monoxide detector was located in the hallway, tested, and functioning properly. There were (1) fire extinguisher located in kitchen fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked in kitchen cabinet. The cleaning agents and toxins was locked in the garage. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.
(Report continued on LIC809C.)
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/24/2024
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During file review LPA observed 5 out of 6 residents has dementia but there physician’s report has not been updated within the required year. 1 staff file review did not have the required TB test. The facility stated staff had the screen and will send to LPA by tomorrow.

The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for resident’s use. A shed full of storage supplies was also observed in the back yard. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the residents.



Exit interview conducted with Rudy Ignacio, House Manager, a copy of this report was provided, and Appeal rights given.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/24/2024 02:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
(5)Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 5 out of 6 residents has dementia but the physcians report is over a year old or do not have a date, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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The facility will ensure the resident physcians report is update and send the updated copy to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
LIC809 (FAS) - (06/04)
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