198603328-5-16-2023-28-AS-LMOA-CRVW5Q-20230516165931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603328
Report Date: 05/16/2023
Date Signed: 05/16/2023 04:59:39 PM

Document Has Been Signed on 05/16/2023 04:59 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	A FAITHFUL HOME OF COVINA		FACILITY NUMBER:	198603328
ADMINISTRATOR:	DUONG, THANG		FACILITY TYPE:	740
ADDRESS:	1084 W GROVECENTER ST.		TELEPHONE:	(626) 244-9999
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY:	6	CENSUS: 5	DATE:	05/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Elizah Arganosa - Caregiver		TIME COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit using the CARE Tool. LPA met with Elizah Arganosa (Caregiver) and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory residents, of which 1 may be bedridden in the age range of 60 and over. The facility has hospice care waiver for 4 residents. The facility is operating within the scope of its license. A tour of the single-story facility included: living room, kitchen, dining area, 5 resident bedrooms, 1 staff bedroom, 2 resident bathroom, backyard, front yard and attached garage. LPA and Elizah Arganosa toured the facility and the following was observed: the front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. Auditory devices were seen on exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in both bathrooms and measured at 116.2 degrees F and 118.4 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility, and were properly operating. There is a carbon monoxide in the dining are and was properly operating. There is one fire extinguisher located in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps kept locked in a kitchen cabinet and are inaccessible to residents. Cleaning supplies and toxins are kept locked under the kitchen sink and are inaccessible to residents. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet. Residents and staff files are centrally stored in the medication cabinet. Residents medication are centrally stored in a locked kitchen cabinet. (Continued to LIC 9099-C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/16/2023

NARRATIVE

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LPA reviewed medication for all 5 residents and observed that medications are documented properly and given as prescribed for 4 out of the 5 residents. Facility did not have 2 medications for Resident 1 (R1). LPA reviewed all 5 resident files and 5 staff files. LPA observed administrator certificate for Thang D Duong – 6052097740 with an expiration date of 06/02/2023. LPA interviewed 2 staff, 1 resident and attempted to interview 4 residents.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was one deficiency observed during the visit (Refer to LIC 809-D). Exit interview held and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2023 04:59 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
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: 05/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care. Facility did not have the medications Erythromycin Ophthalmic 0.5% ointment and Women's Pack Therapeutic Multiple Vitamins & Minerals for Resident 1 (R1). Resident was admitted to the facility on 04/28/2023.
	POC Due Date: 05/17/2023
	Plan of Correction
1 2 3 4	Facility is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, facility will communicate with R1's hospice agency to obtain the missing medication and submit proof to CCLD by 05/23/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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