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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603328
Report Date: 05/21/2024
Date Signed: 05/21/2024 03:57:27 PM


Document Has Been Signed on 05/21/2024 03:57 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 COVINAFACILITY NUMBER:
198603328
ADMINISTRATOR:DUONG, THANGFACILITY TYPE:
740
ADDRESS:1084 W GROVECENTER ST.TELEPHONE:
(626) 244-9999
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:6CENSUS: 6DATE:
05/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Elizah Arganosa, Administrator assistantTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Elizah Arganosa, Administrator assistant. The facility is licensed to serve 6 non-ambulatory residents (age range from 60 years old and over), including 1 bedridden. Facility has hospice care waiver for 4 residents. The annual fees were current. LPA explained the purpose of today's visit and the inspection to the administrator.

During the visit, Care tools, staff/resident interviews and physical plant were conducted; food supply, staff/residents files and medications were reviewed.

The facility is a single-story home located in a residential neighborhood consist of 6 residents bedrooms, 2 bathrooms, a living room, a dining area, kitchen, laundry area in the garage, a garage, and an outdoor activity area at the backyard. The yard has a shaded area and free of debris/ hazard. Bathrooms are clean and operational. Sufficient supply of perishable and non-perishable foods. Adequate linen and personal hygiene supply. Smoke detectors are combined with carbon monoxide detectors and are operable and in compliance. The last Fire/ Emergency Drill was conducted on 05/09/24. Auditory devices are operable. Medications are centrally stored, and locked. Client and staff records have required documentation. Hot water temperature was measured at 115.3 degrees Fahrenheit. Administrator certificate is current and expires on 06/02/25.

Deficiencies were observed and cited per California Code of Regulations, Title 22. See LIC 809D for deficiencies. An exit conference was conducted with Elizah, administrator assistant. LIC 809s and appeal rights were provided.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/21/2024 03:57 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
Incidental Medical and Dental Care 87465(h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained.

This requirement is not met as evidenced by:
Upon reviewing medication and medication log, Resident#3's medication (# of pills in bottle) and medication log did not match. Medication (Rx) of Senna 8.6mg was 1 pill short and no documentation regarding the discrepancy on resident’s Rx log. Licensee did not have an explanation regarding the discrepancy of Rx record.
Deficient Practice Statement
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Based onobservation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2024
Plan of Correction
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Licensee agreed to provide (1) additional medication administration assistance training to all staff and provide proof to the department; (2) review Title 22, Section 87465 and provide a signed statement indicating the review of this section detailing how to prevent future medication errors by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/21/2024 03:57 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
89705(f)(2)
The following shall be stored inaccessible to residents with dementia: (2) …toxic substances…cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Hazardous items, such as laundry detergents, Clorox, and many other bottles of cleaning supplies, were not locked in the garage which was accessible to residents.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Licensee agreed to keep hazardous items locked and inaccessible to residents at the facility. Also, Licensee agreed to provide training to all staff regarding providing care to residents with dementia and provide proof to the department by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3