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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603328
Report Date: 11/26/2024
Date Signed: 11/26/2024 03:27:52 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
11/07/2024 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20241107171143
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:
11/26/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Staff#3, staff in chargeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff is not accepting resident discharged from hospital.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent complaint visit to investigate complaint allegation. LPA met and explained the purpose of today's visit to staff#3 (S3).

The initial complaint visit was conducted on 11/14/24. The investigation consisted of the following: interviews of staff from staff #1 (S1) through staff #3 (S3); interviews of residents from resident#1 (R1) to resident#4 (R4); attempted but unable to interview resident#5 (R5); reviews of resident#1’s record, and physical plant was conducted. LPA obtained copies of staff/resident rosters; and resident files for resident #1 (R1) with relevant information.

Regarding the allegation that staff is not accepting a resident discharged from hospital, it was alleged that staff did not accept resident#5 back to the facility after discharged from the hospital. The investigation revealed of the following:
(-Continued on LIC 9099 C-)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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-20241107171143
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: 11/26/2024
NARRATIVE
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Per resident interviews, four (4) out of four (4) residents could not corroborate the allegation. All residents stated they were able to return to the facility after discharged from hospitals or medical appointments. Per staff interviews, all three (3) staff denied the allegation. It revealed staff would accept residents from hospital upon discharged if the residents' care needs were within the level of care that the facility could provide. Per administrator, Thang Duong, explained, resident#5's level of care had changed which was above the level of care the facility could provided. Per record reviews, administrator was unable to provide any medical assessment, proof of medical changes/prohibited health condition, or any documents showing resident#5's level of care was changed or changed to the level above the care that the facility could provide. As of today, 11/26/24, the facility has not accept resident#5 back to the facility. Thus, the facility violated resident's personal rights.

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D.

Exit interview held with staff#3 (S3). A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20241107171143
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: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87468.1(b)(1)
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(b) All residents in all residential care facilities for the elderly shall be protected from all of the actions... A licensee or facility staff may not take any of the following actions…of a resident: Deny admission to a facility … or discharge or evict a resident from a facility.
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Administrator will review Title 22 regulations and provide a written statement by POC date confirming their understanding of the citation issued. Administrator shall obtain resident’s medical assessment to determine whether there is probable cause not accepting resident back to the facility.
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This requirement was not met by evidence of:

The facility did not accept resident #5 back to the facility after discharged from hospital.
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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: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3