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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603328
Report Date: 06/03/2025
Date Signed: 06/03/2025 03:48:15 PM

Substantiated


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
05/27/2025 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250527081606
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:
06/03/2025
UNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Jenine Oriemo - AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff do not ensure residents bedding is clean and orderly
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced complaint visit to investigate the allegations listed above. LPA met with Jenine Orimeo, administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: LPA obtained copies of the staff and resident roster, reviewed the medications and physician orders for Residents #1 - 5 (R1 - R5), obtained the admissions agreement for R1, obtained serious incident reports involving R1, hospital discharge paperwork for R1, interviewed R1 - R4, and also interviewed Staff #1 - 4 (S1 - S4). LPA attempted to interview R5, however they were not at the facility and at the facility at the time of the visit.

The investigation revealed the following: In regards to the allegation that "Staff do not ensure residents bedding is clean and orderly," it is alleged that R1 has not had their bed sheets cleaned and that it has dried blood stains on it.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
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 6
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
05/27/2025 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250527081606

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:
06/03/2025
UNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Jenine Oriemo - AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Staff abandoned resident at the hospital
Staff are not dispensing medication as prescribed
Staff are not providing adequate transportation services to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced complaint visit to investigate the allegations listed above. LPA met with Jenine Orimeo, administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: LPA obtained copies of the staff and resident roster, reviewed the medications and physician orders for Residents #1 - 5 (R1 - R5), obtained the admissions agreement for R1, obtained serious incident reports involving R1, interviewed R1 - R4, hospital discharge paperwork for R1, and also interviewed Staff #1 - 4 (S1 - S4). LPA attempted to interview R5, however they were not at the facility and at the facility at the time of the visit.

The investigation revealed the following: In regards to the allegation that "Staff abandoned resident at the hospital," it is alleged that R1 was locked out of the facility during their hospitalization.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20250527081606
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: 06/03/2025
NARRATIVE
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During interviews with the residents, three (3) out of four (4) did not corroborate the allegation. One resident stated that they have never been locked out of the facility by the staff. Another resident stated also stated that they have never been locked out of the facility in the past. During interviews with the staff, none of them corroborated the allegation. One of the staff members stated that they were coordinating with the hospital social worker to determine if R1 required a higher level of care before admitting them back to the facility, however they did not lock them out of the facility. Another staff member also explained that they did not lock R1 out of the facility and had allowed her to return following their hospitalization. During the visit LPA confirmed R1 had returned to the facility and was present during the visit.

In regards to the allegation that "Staff are not dispensing medication as prescribed," it is alleged that the R1 was not obtaining their medication as prescribed. During interviews with the residents, none of the residents corroborated the allegation. One of the residents stated that they are obtaining their medications, however they need to make an appointment with their physician in order to obtain a prescription for one of their medications. Another resident interviewed stated that they have had no issues obtaining their medications. During interviews with the staff, none of them corroborated the allegation. One of the staff interviewed stated that R1 was recently hospitalized and was provided with new orders that superseded R1's existing orders because they interacted with each other, but they are dispensing R1's medication as prescribed. Another staff member also explained that they are administering the hospital medication orders to R1 and that R1 has an upcoming scheduled appointment with their physician to update their orders. The incident reports involving R1 confirm their recent hospitalization beginning on 5/23/2025.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20250527081606
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: 06/03/2025
NARRATIVE
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In regards to the allegation that "Staff are not providing adequate transportation services to clients," it is alleged that R1 is not being assisted to their medical appointments by staff. During interviews with the residents, three (3) out of four (4) did not corroborate the allegation. One of the residents interviewed stated that their family take them to their medical appointments and have had no issues with obtaining transportation. Another resident interviewed stated that they have not had problems from getting assistance from facility staff in taking them to medical appointments. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that R1 had declined transportation services which is outlined as an optional service in their admissions agreement. During record review of R1's admissions agreements, it was revealed that they declined the transportation optional service in their admissions agreement.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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.

Exit interview held, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20250527081606
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: 06/03/2025
NARRATIVE
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During interviews with the residents, one (1) out of four (4) residents corroborated the allegation. One of the residents reported that they did have stains on their bed that hadn't been cleaned. The other residents of the facility stated that their linens had been cleaned in a timely manner. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that they do clean the bedsheets of residents and that it is performed once per week. Another staff interviewed also indicated that the bedsheets of residents are cleaned once per week or immediately whenever they become soiled. LPA inspected the beds of the residents of the home and found that R1's bedsheets do have red stains. Photographs were taken of the stains on the bed as well.

Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D.

Exit interview was held and a copy of the report along with the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20250527081606
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2025
Section Cited
CCR
87307(a)(3)(C)
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(a) Living accommodations and grounds shall be related to the facility's function. (...) The following rules shall apply: (3) Equipement and supplies (...) the licensee shall assure provision of: (C) Clean linen, including (...) top bed sheets (...) to ensure that clean linen is in use (...) at all times.
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Administrator is to ensure that clean linens are available to residents at all times. Administrator is to change or clean the linen in R1's room and send proof of correction to LPA by the POC due date.
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The regulation is not bed as evidenced by:
Based on observation, LPA determined that the bed sheets of R1 have multiple stains on them that resemble blood stains, which poses a potential health and safety risk to residents 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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6