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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602923
Report Date: 09/05/2024
Date Signed: 09/05/2024 05:10:32 PM

Substantiated


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
08/27/2024 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20240827084017
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:
09/05/2024
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Administrator Teresa KholomaTIME COMPLETED:
05:24 PM
ALLEGATION(S):
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Staff did not ensure residents dresser was in good repair
INVESTIGATION FINDINGS:
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On 9/5/24, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit to investigate the allegation listed above. 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 03:10 p.m., and LPA explained the purpose of the visit. The Administrator arrived at 4:25 p.m. to assist with the visit.

During today’s visit LPA toured the facility with the House manager. LPA requested a copy of the resident roster and staff roster via email. LPA took photos of the dresser in R1’s room. LPA interviewed: Administrator and a total of three (3) staff who shall be referred to as S1 through S3. LPA interviewed a total of 3 residents who shall be referred to as: R1 through R3. Due to Resident #4 through Resident #5 diagnosis LPA could not conduct interviews. The last resident (R6) was hospitalized at the time of the visit. (Report continued on 9099c).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
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 3
Control Number 28-AS-20240827084017
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: 09/05/2024
NARRATIVE
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The investigation reveals the following: Regarding " Staff did not ensure residents dresser was in good repair”. It is alleged that R1’s dresser is broken. During the visit LPA interviewed the administrator. The Administrator stated the dresser was fixed before but R1 add heavy items into the draw. 2 out of 3 staff confirmed the Administrators comment of the dresser being fixed and broke again. 1 out of 3 staff stated they are unsure about what is going on with the dresser. 1 out of 3 residents interviewed stated the dresser drops when pulling it open. LPA observed the drawer in full of documents and is broken. During the conversation with the Administrator, they stated they will replace the draw.

Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.



Exit Interview Conducted with Administrator/ Appeal Rights Provided / A Copy of the Report Issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240827084017
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2024
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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The facility shall ensure R1's dresser is in good repair at all times. Photo proof of the correction is due to the LPA by the POC due date.
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Based on observation and interview, the licensee did not comply with the section cited above in which the Licensee did not
ensure R1's dresser is in good repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3