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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603328
Report Date: 11/05/2024
Date Signed: 11/05/2024 03:56:33 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
10/28/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241028162318
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: 4DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Thang "Steven" Duong, AdministratorTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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1. Staff not providing resident with meals in a timely manner.
2. Staff does not provide nutritious meals to residents.
3. Staff deprived resident of additional servings of food.
4. Staff discriminates against resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted the complaint investigation on the allegations listed above. LPA arrived unannounced and met with Staff, Roldan Kiseo. Administrator, Steven Duong, arrived shortly after to assist with the visit. The purpose of the visit was explained.

LPA obtained copies of the staff and resident rosters, toured the facility, and interviewed Staff and Residents.
The investigation revealed the following:

Allegations - Staff not providing resident with meals in a timely manner, Staff do not provide nutritious meals to residents, and Staff deprived resident of additional servings of food. The administrator and staff were interviewed regarding the food service provided to residents. They stated that residents are served 3 meals a day and provided with snacks. Breakfast is served to them depending on their wake-up times.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
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 2
Control Number 28-AS-20241028162318
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A FAITHFUL HOME OF COVINA
FACILITY NUMBER: 198603328
VISIT DATE: 11/05/2024
NARRATIVE
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They get lunch around noon and dinner about 5:30pm. If a resident chooses to eat at different times, they will provide them the meals when they want it. Staff stated they cook a variety of nutritious foods for them. They ask the residents what they like to eat and will go shopping for the items. Their meals include a meat, grain, vegetables, fruits, and juice. LPA observed fresh fruits and vegetables and frozen meats in the refrigerator. Staff stated they use fresh ingredients and seldom canned goods. If a resident requests for more servings, staff will give it to them. LPA interviewed 2 residents who stated they get 3 meals a day plus snacks. They are provided more if they want it. They stated the meals include meats, rice, vegetables, and fruits.

Allegation - Staff discriminates against resident. It is alleged that Staff stated that a resident is “fat enough and doesn’t need much food.” LPA interviewed the Administrator and Staff. Staff interviewed denied saying the phrase and stated that Resident #1 (R1) will comment on his/her own weight. They stated they do not deprive resident(s) any food. They will ask residents what they like to eat and make it for them. Staff stated they treat the residents the same and with respect. Two residents were interviewed, and they do not feel discriminated living here.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.



An exit interview was conducted with the Administrator. A copy of this report along with the appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2