<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603328
Report Date: 01/24/2025
Date Signed: 01/24/2025 05:00:42 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
10/10/2024 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20241010120330
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:
01/24/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Staff#2, staff in chargeTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained pressure sore(s) while in care of staff.
Staff not properly cleaning resident resulting in multiple UTI’s.
Staff does not keep facility free from pests.
Staff does not clean resident’s room.
Staff did not assist resident in a timely manner.
Staff not following resident’s meal plan.
Staff did not properly prepare resident’s food.
Resident sustained injury while in care.
Staff does not notify resident’s authorized representative of changes in resident’s medical.
Staff did not provide resident with proper toiletries causing resident skin to be irritated.
Staff left hazard chemicals accessible to residents.
Facility does not post menu.
Staff does not have planned activities for residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent complaint visit to investigate the complaint allegations listed above. During today’s visit, LPA met with staff#2 (S2), staff in charge. The purpose of today's visit was explained to S2 at the facility and Licensee Thang Duong over the phone.

The initial investigation visit was conducted on 10/17/24 and the subsequent visit was conducted on 01/07/25. The investigation consisted of the following: interviews of staff from staff #1 (S1) through staff #3 (S3); interviews of residents from resident#2 (R2) to resident#6 (R6); attempted but unable to contact and interview resident#1 (R1); reviews of resident#1’s record, and physical plant was conducted. LPA obtained copies of staff/resident rosters and resident files of resident #1 (R1) with relevant information.

The investigation revealed of the following:
(-continued on LIC 9099C- pg 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
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 6
Control Number 28-AS-20241010120330
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: 01/24/2025
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
Regard the allegation of resident sustained pressure sore(s) while in care of staff, it was alleged that resident sustained pressure ulcers. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents stated staff had provided proper care to them and none of them have pressure injuries. Per staff interviews, all three (3) staff denied the allegation. It revealed staff would proper care to residents according to residents’ care needs to prevent pressure injuries or bedsores. Per record review, resident who claimed to have pressure injuries was under home health care. The facility staff had a log to document the care provided to resident, such as reminded or assisted resident to reposition and provided cares to clean resident’s bottom per home health nurse notes. LPA recalled the observation from the other visits prior to resident’s discharge, staff had assisted resident to get up from the bed to the recliner and reminded resident to turn in bed from left to right/right to left. Thus, there were not preponderance of evidence showing resident sustained pressure sore(s) while in care.

Regard the allegation of staff not properly cleaning resident resulting in multiple UTI’s, it was alleged staff did not take a resident to the bathroom causing resident to have UTIs. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents stated staff would assist them to use the bathroom as needed and clean them afterward. None of the residents had UTI while in care. Per staff interviews, all three (3) staff denied the allegation. It revealed staff would assist residents who needed toileting assistance to go to the bathroom and provided proper cleaning to residents. Per record review, staff had kept track of providing toileting assistance to the resident who claimed to have UTIs, such as changing urine pads in bed when wet and assisting resident to get up going to the bathroom. Therefore, there were not preponderance of evidence showing staff failed to clean resident resulting in multiple UTI’s.

Regard the allegation of staff does not keep facility free from pests, it was alleged that staff members were leaving the kitchen / garage door open causing flies and mosquitoes to fly in resident’s room. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents’ interviews revealed they did not observe flies and mosquitos in their rooms. Their rooms did not have pest issues. Per staff interviews, all three (3) staff denied the allegation.
(-continued on LIC 9099C- pg 3 )
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20241010120330
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: 01/24/2025
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
It revealed staff would keep the doors closed to prevent flies to fly in or pest issues. Per observation, kitchen door and garage doors were closed during all investigation visits. Thus, staff did not fail to keep the facility free from pests.

Regard the allegation of staff does not clean resident’s room, it was alleged staff did not mop resident’s room floor and keep resident’s room tidy. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents’ interviews revealed staff cleaned their rooms daily and mopped the floor at least once a week or as needed. Their rooms were clean and tidy. Per staff interviews, all three (3) staff denied the allegation. It revealed staff would mop the resident’s room floor every morning as a daily routine and mop the floor another time during the day as needed. Per observation, residents’ rooms were clean and no trash on the floors. The facility’s floor, including all residents’ rooms, was observed to be cleaned and was not sticky when walked on it. Therefore, residents’ rooms were observed to be tidy and clean.

Regard the allegation of staff did not assist resident in a timely manner, it was alleged staff did not come to assist resident within a reasonable amount of time. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents’ interviews revealed staff would come to assist them in about 5 – 10 minutes after they called for help. Sometimes, when staff was assisting other residents, staff would notify the resident who called for assistance that staff was aware the resident’s call and would provide assistance promptly. Per staff interviews, all three (3) staff denied the allegation. It revealed staff would assist residents as soon as they were called. Per observation, staff responded to residents’ calls promptly during the visits. Therefore, staff would assist resident in a timely manner.

Regard the allegation of staff not following resident’s meal plan, it was alleged that staff did not provide meal to resident per resident’s meal plan. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents’ interviews revealed staff had followed resident’s meal plan to provide meal to them. Sometimes, residents would ask for alternative meals and staff were able to provide it to them.
(-continued on LIC 9099C- pg 4 )
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20241010120330
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: 01/24/2025
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
Per staff interviews, all three (3) staff denied the allegation. It revealed staff had followed resident’s meal plan when providing meal to residents. Therefore, staff had followed resident’s meal plan.

Regard the allegation of staff did not properly prepare resident’s food, it was alleged staff failed to completely puree the meat on the food tray provided to a resident. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents’ interviews revealed they were not on a pureed food diet. Staff would prepare residents’ meals accordingly. Alternate food menu was available. Per staff interviews, all three (3) staff denied the allegation. Staff was trying to provide a variety of food to resident who was on a soft food diet, such as tuna fish sandwiches, which the tuna fish was not necessarily completely pureed. Per record review, resident needed soft food diet. Therefore, staff had properly prepared resident’s food to resident who had special diet need.

Regard the allegation of resident sustained injury while in care, it was alleged resident had an unwitnessed fall while in care. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents’ interviews revealed either residents had never have fallen while in care or staff would provide immediate assistance to residents and notify their responsible parties immediately. Per staff interviews, all three (3) staff denied the allegation. Staff would assist residents if residents fell. As reported by resident’s responsible party, the resident did not call for assistance prior to falling. Staff had provided immediate assistance to resident when staff aware of the resident’s fall. Staff had notified administrator and resident’s responsible parties. Per record review, administrator had reported the incident to licensing and notified resident’s responsible party. The facility had taken a follow up action and an action of prevention for future occurrence. Therefore, staff had taken proper action after the unwitnessed fall of a resident.

Regard the allegation of staff does not notify resident’s authorized representative of changes in resident’s medical, it was alleged that facility staff did not notify resident’s responsible party about resident’s medical change, such as losing weight. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents’ interviews revealed staff would notify residents and their responsible parties immediately if residents had medical changes.
(-continued on LIC 9099C- pg 5 )
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20241010120330
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: 01/24/2025
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
Per staff interviews, all three (3) staff denied the allegation. Staff would always discuss residents’ medical changes to authorized representatives. Per record review, staff had discussed the resident’s authorized representative about resident’s medical changes. In addition, that resident’s authorized representative had come to visit resident almost daily; therefore, the representative should be able to observe resident’s changes, such as weight lost. Therefore, staff did not fail to notify resident’s authorized representative of changes in resident.

Regard the allegation of staff did not provide resident with proper toiletries causing resident skin to be irritated, it was alleged staff did not clean resident’s bottom with sensitive skin wipes which cause resident’s skin to turn red. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents’ interviews revealed residents did not have skin issues due to toiletries products. Per staff interviews, all three (3) staff denied the allegation. Staff had used the sensitive skin wipes to assist resident as instructed by the resident’s authorized representative. Per record review, administrator and staff had followed up with the home health nurse regarding the resident’s skin redness. Therefore, staff had provided resident with proper toiletries.

Regard the allegation of staff left hazard chemicals accessible to residents, it was alleged staff left the cleaning products in the bathroom accessible to residents. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents’ interviews revealed residents did not aware of the bathroom cleaning products left in the bathroom. Per staff interviews, all three (3) staff denied the allegation. Staff stated they cleaned the bathroom with cleaning products and would have the products in the bathroom while cleaning. Staff would lock the cleaning supplies in a locked storage room after use. LPA did not observe hazard cleaning chemicals in the bathroom. Those products were observed to be locked in the storage room. Therefore, the cleaning supplies and hazard chemicals were not accessible to residents.

Regard the allegation of facility does not post menu, it was alleged the resident’s food menu is not visible for residents. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation.
(-continued on LIC 9099C- pg 6 )
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20241010120330
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: 01/24/2025
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
Residents’ interviews revealed residents could see the food menu when they walked in the kitchen. Per staff interviews, all three (3) staff denied the allegation. Staff stated the food menu was posted in the kitchen wall. LPA observed a food menu was posted on kitchen’s wall and was visible when walked in the kitchen. Therefore, a resident’s food menu was posted in the facility kitchen.

Regard the allegation of staff does not have planned activities for residents, it was alleged staff did not abide by the contact and planned activities for residents. Per resident interviews, five (5) out of five (5) residents could not corroborate the allegation. Residents’ interviews revealed residents had planned activities twice a week or so. Residents stated, sometimes, they did not want to participate even staff came to invite them. Per staff interviews, all three (3) staff denied the allegation. There was an activity coordinator from an outsource agency who came to the facility on a regular basis to encourage residents to participate activities. Staff could not force residents to participate if they did not want to. Per observation from different visits of the facility, LPA observed an activity coordinator came to the facility doing activities with residents on different days. Residents were invited to participate but a few residents declined the invitation. Therefore, staff had planned activities for residents.

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 allegations are UNSUBSTANTIATED.

An exit interview was conducted with S2 and findings were discussed. A copy this report was provided at the time of visit.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6