198603328-4-2-2024-28-AS-RORN-D7FMXU-20240723100027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603328
Report Date: 04/02/2024
Date Signed: 04/02/2024 04:09:44 PM

Unsubstantiated

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
03/28/2024 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20240328143029

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: 6	DATE:	04/02/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Elizah Arganosa, administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff slapped resident.
Staff did not report incidents as required.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Tao conducted unannounced complaint investigation for the allegations listed above. During today’s visit, LPA met and explained the purpose of today's visit to administrator, Elizah Arganosa.

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 failed to interview resident #5 (R5); failed to interview resident #6 (R6) since R6 was out; interview with visitor#1 (V1); 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.

(-continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

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 2

Control Number 28-AS-20240328143029

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: 04/02/2024

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
26
27
28
29
30
31
32

The investigation revealed that:

In regard of the allegation staff slapped resident, it was alleged that facility staff slapped resident while in care. The investigation revealed the following: four (4) out of five (5) residents interviewed revealed staff treated residents nicely with respect and had never slapped them. One (1) out of five (5) residents was non comprehend and unable to be interviewed. Per resident interviews, residents were able to verbalize their needs. Per staff interviews, all three (3) staff denied the allegation. Per visitor interview, it revealed staff were treating residents nicely and did not observe staff hitting or slapping residents. Per file review, residents’ progress notes did not indicate resident had reported being slapped by staff. Staff had in-service training on residents’ right and abuse prevention. Per observation, residents looked fine and had open conversation with staff regarding the care they needed. Thus, there were not preponderance of evidence showing staff slapped resident.

In regard of the allegation staff did not report incidents as required, it was alleged that staff did not report resident’s falls to licensing. The investigation revealed the following: three (3) out of five (5) residents interviewed revealed residents had never fallen while in care. One (1) out of five (5) residents interviewed revealed resident had fell twice, uninjured, since moved in. Staff provided immediate care to resident after the falls. Per staff interviews, all three (3) staff stated only one (1) resident had fell since admitted to the facility. Staff provided immediate care to resident after the falls and reported the resident’s falls to administrator and administrator reported the incidents accordingly. Per file review, two (2) incident reports, dated 10/20/23 and 02/13/24, regarding the resident who claimed had fell twice were reported to licensing. Per staff training review, in-service training on reporting incidents was conducted. Thus, there were not preponderance of evidence showing staff did not report incidents as required.

Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above.

Although the allegations may have happened or are valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with administrator and findings were discussed. A copy this report was provided at the time of visit.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2