198603328-7-18-2024-28-AS-RORN-D7FPDF-20240723111327

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603328
Report Date: 07/18/2024
Date Signed: 07/18/2024 12:12:47 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
11/07/2023 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20231107092544

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:	07/18/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Duong (Steven) Thang, administrator / Licensee		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff did not ensure resident was receiving adequate fluid intake while in care.
Staff do not ensure resident is provided bathing assistance.
Staff do not ensure resident is provided clean clothing.
Staff do not ensure resident is provided with toileting assistance.
Staff did not ensure an adequate care needs assessment plan was conducted for resident in care.
Facility is not following doctor order for medications.
Faciliity is not adivsing residents responsible party of residents health status.
Facility staff are failing to store resident items in resident’s room in a safe manner.
Faciliity did not accept resident back ot facility upon discharge from hospital.

INVESTIGATION FINDINGS:

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***This report serves as an amendment and supersedes the original complaint investigation report created on 07/16/24. The findings remain as unsubstantiated. ***

Licensing Program Analyst (LPA) Tao conducted a subsequent, unannounced complaint visit for delivering finding. The initial unannounced 10-day complaint visit was conducted on 11/15/23 and a subsequent visit was conducted on 07/16/24. During today’s visit, LPA met and explained the purpose of today's visit to administrator,.

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 unable to interview resident #5 (R5); 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: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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 5

Control Number 28-AS-20231107092544

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: 07/18/2024

NARRATIVE

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***This report serves as an amendment and supersedes the original complaint investigation report created on 07/16/24. The findings remain as unsubstantiated. ***

The investigation revealed the following:

In regard to staff did not ensure resident was receiving adequate fluid intake while in care, it was alleged that resident was dehydrated due to not having sufficient fluid intake. Per resident interviews, four (4) out of five (5) residents interviewed revealed staff treated residents nicely and provided them fluid, including coffee, teas, and water, three times daily with meals and three to four times daily with medication. One (1) out of five (5) residents was sleeping and unable to be interviewed. During the interview, all residents were able to verbalize their needs. Per staff interviews, all three (3) staff denied the allegation. It revealed staff provided residents with water/fluid with meals and medication multiple times a day. Besides, a jar of water or a 8 oz cup of water with lid was provided in each room near resident’s bed. Per observation, residents had fluid during mealtimes and medication, and additional fluid, such as a jar of drinking water for resident’s consumption, was observed in each room. Thus, there were not preponderance of evidence showing resident did not receive adequate fluid intake while in care.

In regard to staff do not ensure resident is provided bathing assistance, it was alleged that facility did not clean resident correctly and did not provide showers to resident. All four (4) residents interviewed revealed residents were bathed at least twice / weekly or more as needed. Per staff interviews, all staff denied the allegation. It revealed residents had their bathing schedules. Residents were scheduled to be bathed daily. Staff would clean residents after changed diapers or as needed. Sometimes, residents would and had rights to decline to be bathed. Per observation, residents were observed to be clean with no foul odor. Thus, staff did not fail to provide bathing assistance to resident while in care.

In regard to staff do not ensure resident is provided clean clothing, it was alleged that staff did not ensure resident was placed in clean clothing every day. All four (4) residents interviewed revealed residents had their clothes changed daily. Per staff interviews, all staff denied the allegation. It revealed residents’ clothes were changed daily. Staff would encourage residents to change clothes if residents declined to be changed. As mentioned above, residents were observed to be clean with no foul odor. Thus, resident is provided with clean clothing.
(-continued in LIC 9099 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20231107092544

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: 07/18/2024

NARRATIVE

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***This report serves as an amendment and supersedes the original complaint investigation report created on 07/16/24. The findings remain as unsubstantiated. ***

In regard to staff do not ensure resident is provided with toileting assistance, it was alleged that staff allowed resident to sit in soiled diaper and did not provide toileting assistance. All four (4) residents interviewed revealed staff would change residents’ diapers when got soiled and change their clothes as needed. Residents would tell staff when they needed to go to the bathroom or staff would check on residents throughout the day. Per staff interviews, all staff denied the allegation. It revealed staff would check on residents who needed toileting assistances or check resident’s diaper every 2 hours or so. Staff had in-service training on residents’ right and proper care to elderly. Per observation, staff would ask and assisted residents to go to the bathroom during the investigation visit. Thus, residents were provided with toileting assistance.

In regard to staff did not ensure an adequate care needs assessment plan was conducted for resident in care, it was alleged administrator did not do proper care needs assessment on resident when resident was ready to discharge from the hospital. All four (4) residents interviewed revealed staff would assess them or checked and asked them questions upon their returns to the facility after discharged from hospitals. Per staff interviews, all staff denied the allegation. Administrator would assess resident when resident was ready to discharge from the hospitals. Per record review, resident’s assessment was conducted, and progress notes were updated regularly. Thus, adequate care needs assessment plan was conducted for resident in care.

In regard to facility is not following doctor orders for medications, it was alleged that the staff allowed resident to sleep and did not waking resident up to ask resident to take the medication as prescribed. All four (4) residents interviewed revealed staff would wake them up for medication and they were not aware of any missing medication. Per staff interviews, all staff denied the allegation. Staff had followed doctor’s instruction on providing the prescribed medication to residents. Per record review, resident’s medical records did not show missing medication. Staff had in-service training on residents’ medication administration. Per observation, staff would wake up residents for taking medication. Thus, facility is following doctor orders for medications.

(-continued in LIC 9099 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20231107092544

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: 07/18/2024

NARRATIVE

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***This report serves as an amendment and supersedes the original complaint investigation report created on 07/16/24. The findings remain as unsubstantiated. ***

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, Steven, 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: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 28-AS-20231107092544

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: 07/18/2024

NARRATIVE

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***This report serves as an amendment and supersedes the original complaint investigation report created on 07/16/24. The findings remain as unsubstantiated. ***

In regard to facility staff are failing to store resident items in resident’s room in a safe manner, it was alleged that resident’s items were placed up high which items may have risks of falling on resident. All four (4) residents interviewed revealed their items were not placed up high and they did not recall any items had fallen on them. Per staff interviews, all staff denied the allegation. Staff were aware of the safety needs when storing residents’ items. Per record review, staff had in-service training on residents’ safety. Per observation, residents’ items were not stored up high. Passageways and walkways in the facility / residents’ rooms were free from obstructions. Therefore, residents’ rooms were furnished appropriately and in compliance.

In regard to facility is not advising residents responsible party of resident’s health status, it was alleged that staff did not inform the resident’s doctor and responsible party regarding a resident’s health status. All four (4) residents interviewed revealed staff would inform their responsible parties about their physical health status. Per staff interviews, all staff denied the allegation. Administrator and staff would notify residents / responsible parties if there were updates about resident’s health condition changes. Per record review, resident’s records were updated with medical and physical care needs. Staff had in-service training on reporting residents’ physical / medical changes. Therefore, there were not preponderance of evidence showing facility staff failed to notify residents responsible party of resident’s health status.

In regard to facility did not accept resident back to the facility upon discharge from hospital, it was alleged that staff did not accept resident back to facility after being discharged from hospital. All four (4) residents interviewed revealed staff would accept them back after discharged from hospitals. Per staff interviews, all staff denied the allegation. Administrator had accepted the resident back after discharged from the hospital. Per record review and LPA’s observation, resident had returned and residing at the facility. Therefore, facility had accepted the resident after discharged from hospital.

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.
(-continued in LIC 9099 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC9099 (FAS) - (06/04)

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