198603328-6-1-2022-28-AS-NMAN-CEYRB3-20220601125203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603328
Report Date: 06/01/2022
Date Signed: 06/01/2022 12:53:30 PM

Document Has Been Signed on 06/01/2022 12:53 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 COVINA		FACILITY NUMBER:	198603328
ADMINISTRATOR:	DUONG, THANG		FACILITY TYPE:	740
ADDRESS:	1084 W GROVECENTER ST.		TELEPHONE:	(626) 244-9999
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY:	6	CENSUS: 6	DATE:	06/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Staff Elizah Arganosa		TIME COMPLETED:	12:45 PM

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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met caregiver Elizah Arganosa and explained the reason for the visit. Administrator was notified of the visit. Physical Plant was toured, residents files and medication records were reviewed, staffs files records reviewed and food supply was inspected. The facility is licensed for six (6) non ambulatory residents over the age of 60 of which 1 may be bedridden. Facility is approved for four (4) hospice residents.

The facility is a single story structure located in a residential neighborhood. It consists of the following: 6 bedrooms, 2 bathrooms, living room, dining area, kitchen, attached garage, laundry area in the garage, backyard with shaded patio area. Front yard is landscaped with grass.

LPA toured the facility. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways were free of obstruction. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit.

All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was 116.1 degrees which is within the required 105 - 120 degrees. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. Sharps, cleaning supplies are locked and inaccessible to residents.

The common areas include the living room and dining area are clean and have the required furniture.
Continue 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022

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 COVINA	FACILITY NUMBER: 198603328
	VISIT DATE: 06/01/2022

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Carbon monoxide detectors were in compliance and operational. Fire extinguisher observed in the kitchen fully charged. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed residents records to confirm emergency contact is updated and residents have health screenings on file. Staff records were reviewed to confirm health screenings and fingerprint clearances. LPA reviewed residents medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided to Elizah Arganosa

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022

LIC809 (FAS) - (06/04)

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