198603328-8-28-2023-28-AS-TVAO-CW9M5R-20231003091843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603328
Report Date: 08/28/2023
Date Signed: 08/28/2023 03:42:11 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
08/21/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230821113638

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:	08/28/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Elizah Arganosa, Assistant Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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1. Residents in care have access to centrally stored medications.
2. Staff do not ensure the facility is kept clean.
3. Staff do not provide proper incontinence care to residents in care.
4. Staff are unable to communicate with residents in care.
5. Residents are not provided with proper food service.
6. Residents are not provided proper medication.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Cynthia Chan and Sanjay Vaid conducted a complaint investigation for the allegations listed above. LPAs arrived unannounced and met with Assistant Administrator, Elizah Arganosa. The purpose of this visit was explained.

The investigation consisted of the following:
LPAs toured the facility and collected documents such as staff roster, resident roster, and the food menu. LPAs reviewed medications and files for Residents #1 - #5 (R1 – R5). Interviews were conducted with the Administrator, assistant administrator, 2 Staff, and 3 Residents.

The investigation revealed the following:
1. Allegation - Residents in care have access to centrally stored medications. It is alleged that there are creams and ointments placed in the resident room.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230821113638

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: 08/28/2023

NARRATIVE

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LPAs toured the facility and did not observe any medications including medicated creams or ointments in the bedrooms. Per Staff interviews, after the topical creams or ointments are used, they would put away so residents do not have access to them. The centrally stored medications are locked in the kitchen cabinet and not accessible to residents.

2. Allegation - Staff do not ensure the facility is kept clean. It is alleged that the facility is not clean and the resident rooms are not cleaned regularly. Per the assistant administrator, staff clean daily and deep clean the resident rooms 3 times a week. Staff interviewed stated they are often cleaning to keep the facility clean. When residents have a bowel movement, they change them and dispose the soiled diapers immediately to avoid any odor. During the tour today, LPAs observed the facility to be well maintained. There was no unpleasant odor and the resident rooms appeared clean. One of the residents stated that staff clean their rooms and keeps the house clean.

3. Allegation - Staff do not provide proper incontinence care to residents in care. It is alleged that the diapers are not changed timely nor cleaned correctly. Per staff interviewed, they stated that they check the diapers every few hours. If the diaper is soiled, they will change the resident and make sure they are thoroughly cleaned. One of the residents stated the staff change their diapers when it is soiled.

4. Allegation - Staff are unable to communicate with residents in care. It is alleged that some of the care staff are unable to communicate in English. Per Staff interviewed, all the caregivers at the home can communicate in English although it is not their native language. LPAs observed the staff speaking to the residents in English and residents were responding back. Residents stated the staff speak to them in English and they can understand them.

5. Allegation - Residents are not provided with proper food service. It is alleged that the facility is not serving healthy meals to residents. LPAs inspected the perishable items and observed a variety of meats, vegetables, and fruits. Per the staff, they serve the meals based on residents’ preferences and dietary restrictions. They stated the meals include different items from the food groups. One of the residents stated the food is good and is offered a variety of food.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230821113638

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: 08/28/2023

NARRATIVE

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6. Allegation - Residents are not provided proper medication. Per the staff, all the residents take their medications daily and on time. There were no recent medication errors. They follow the physician’s orders to administer medications. LPAs reviewed the medications for all 5 residents. There were no discrepancies found for the routine medications. Staff are administering and documenting the medications when given.

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 Elizah Arganosa. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC9099 (FAS) - (06/04)

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