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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602923
Report Date: 10/17/2024
Date Signed: 10/17/2024 04:14:22 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
10/09/2024 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20241009132138
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:
10/17/2024
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:House Manager Rudy IgnacioTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff are not meeting resident's showering needs.
INVESTIGATION FINDINGS:
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On 10/17/24, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival, LPA met with House Manager (Rudy Ignacio) and explained the reason for the visit. LPA contacted and interviewed the Administrator (Teresa Kholoma) via phone.

During today’s visit LPA toured the facility with the House Manager and took photos. LPA obtained a copy of the resident roster, staff roster and Resident #1 Admission Agreement. LPA requested a copy of R1’s physician’s report via email. LPA asked for a shower schedule, to which the House Manager stated they do not have a schedule. 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. LPA interviewed the responsible party for R1 and R4 who shall be referred to as Witness #1 and Witness #2 (W1 and W2). (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: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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-20241009132138
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: 10/17/2024
NARRATIVE
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The investigation reveals the following: Regarding " Facility staff are not meeting resident's showering needs”. It is alleged that the facility placed a time limit on R1’s showers. According to R1 and W1, a meeting was held with the Administrator regarding R1 taking more than one (1) hour to the shower. The Administrator told R1 to start taking 40 minutes showers. R1 denied taking more than one (1) hour to shower. R1 stated they were also washing their face and taking care of their toileting needs. R1 and W1 further stated that there are times when staff are not in the bathroom when R1 is showering, and R1 felt it was unfair to include that in there “time limit”. R1 stated due to their unique health condition they do need a longer time in the shower. The Administrator stated they did not place a time limit, but came up with an agreement with the resident and their family. Based on resident interviews, it was determined that R2 does not take showers, but sponge baths. In the interview with R3, they stated that they were independent and conduct their own sponge baths without the assistance of staff. S1 stated they were not there during the meeting with family, but only one (1) resident takes a sponge bath, and the other residents are showered daily. S2 confirmed R1 not only takes showers, but also uses the toilet. S2 further confirmed leaving R1 in the bathroom for no more than 15 minutes whenever another resident needs assistance. LPA concluded that all residents do not require the same amount of time, and reviewed R1’s Physicians Report stating “keep perineal area clean and dry” due to medical condition.

Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above Allegation 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: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20241009132138
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: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/24/2024
Section Cited
CCR
87468.2(a)(6)
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(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility.
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The licensee will ensure the resident can make their own choices. Staff training will be conducted regarding residents personal rights. A copy of the traing is due to LPA by POC due date.
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This requirement was not met as evidenced by:
Based on interviews R1 was unable to make the decison concerning their daily lives, which is potentially a health,which poses an immediate 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: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3