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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603328
Report Date: 10/17/2024
Date Signed: 10/17/2024 05:09:08 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
10/10/2024 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20241010120330
FACILITY NAME:A FAITHFUL HOME OF COVINAFACILITY NUMBER:
198603328
ADMINISTRATOR:DUONG, THANGFACILITY TYPE:
740
ADDRESS:1084 W GROVECENTER ST.TELEPHONE:
(626) 244-9999
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:6CENSUS: 5DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Elizah Arganosa, administrator assistantTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility has leaking water.
Facility equipment pose a hazard to residents.
Staff does not ensure call button accessible to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegations listed above. LPA met Elizah Arganosa, administrator assistant. LPA explained the purpose of today's complaint investigation visit.

The investigation consisted of the following: LPAs obtained staff roster, resident roster, interviewed resident#1 (R1) and resident#2 (R2), interviewed staff #1 (S1) and conducted a physical plant.

The investigation revealed the following:

In regard of allegation that facility has leaking water, it was alleged that a pipe outside the front door that is leaking water. LPA interviewed staff and staff corroborated the allegation. LPA toured the facility and observed a pipe outside the front door was leaking water during the visit. The facility was not in good repair.
(-continued in LIC 9099C-)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST 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 4
Control Number 28-AS-20241010120330
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 COVINA
FACILITY NUMBER: 198603328
VISIT DATE: 10/17/2024
NARRATIVE
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In regard of allegation that facility equipment poses a hazard to residents, it was alleged that the audio devices on the back door that access to the patio was not operable. LPA interviewed staff and staff corroborated the allegation. LPA tested the audio devices on the patio door and observed that it did not sound off when the patio door opened. Thus, it poses a hazard to residents.

In regard of allegation that staff does not ensure call button accessible to resident, it was alleged that the call button was not accessible to resident. LPA interviewed residents and revealed that their call buttons were not within their reach and not accessible to them. Per staff interview, staff denial the allegation. LPA toured the residents’ rooms and observed the call buttons were either left on the “beside table” against the bed or attached to the drawer next to the bed where residents could not reach. Therefore, the call buttons were not accessible to residents.

Based on LPAs’ observations and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found SUBSTANTIATED.

Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D.

An exit interview was conducted with Elizah Arganosa, administrator assistant. A hard copy of this report and appeal right were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST 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 4
Control Number 28-AS-20241010120330
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 COVINA
FACILITY NUMBER: 198603328
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2024
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times.

The requirement is not met by evidence of:
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Licensee agreed to provide the repair the leaking water pipe and the audit device on the patio door by POC due date. Licensee agreed to provide the proof of the repair to Licensing.
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A pipe outside the front door was leaking water and the audio devices on the back door that access to the patio was not operable. Based on interviews and observation, the Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/25/2024
Section Cited
CCR
87468.1(a)(2)
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To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

The requirement is not met by evidence of:
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Licensee agreed to provide a necklace to attach to the call buttons and make it accessible to the residents by POC due date.
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The call button was not accessible to residents.
Based on interviews and observation, the Administrator did not comply with the section cited above which poses 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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST 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: 4 of 4