198603491-3-2-2023-28-AS-CWOG-CPJW27-20230302155353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603491
Report Date: 03/02/2023
Date Signed: 03/02/2023 07:56:04 PM

Document Has Been Signed on 03/02/2023 07:56 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:	COVENANT CARE HOME		FACILITY NUMBER:	198603491
ADMINISTRATOR:	AMANYA, HERBERT BAGORO		FACILITY TYPE:	735
ADDRESS:	2027 SHAMWOOD ST		TELEPHONE:	(818) 571-2247
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 4		CENSUS: 4	DATE:	03/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Teddy Idehen		TIME COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Christine Wong conducted the unannounced Annual Inspection and met with DSP Guadalupe Garcia who allowed the entry of the facility. Shortly after the facility manager Teddy Idehen arrived and explained the reason of today's visit and will be using the Compliance And Regulatory Enforcement (CARE) Tools to inspect the facility.

The home is a single story house and it includes dining area, kitchen, living room, laundry room, staff bathroom and shower, three clients bedrooms, one client bathroom and attached garage. The fire clearance is cleared for four (4) ambulatory clients.

The following domains were reviewed during today's visit: Infection control, Physical Plant and Environmental, Operational Requirements, Food Service, Staffing, Personnel Record-Training

A tour of the entire home, inside and outside, was conducted and the following were observed:

The living room, dining area and kitchen were furnished and equipped with the appropriate furniture, sitting and equipment for it's designated use. The fire place in the living room was covered with a Fireplace Vent.
The bedroom#1 and #3 were furnished with one full sized bed, one dresser, one night stand and one chair and a permanent closet The appropriate clean linen were observed on the bed.
The bedroom#2 were furnished with two twin sized bed, two dressers, two night stand and two chairs and a permanent closet. The appropriate clean linen were observed on the bed.

(See LIC 809C for continuation)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 6

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: COVENANT CARE HOME	FACILITY NUMBER: 198603491
	VISIT DATE: 03/02/2023

NARRATIVE

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The client's bathroom was observed with walk in shower, double sink and a toilet. Loose faucet were observed. Water temperature were tested and read 98.6 degrees F which was below the Title 22 regulation requirement.
A carbon monoxide detectors were tested and operational
Perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed maintained on the premises and stored in the kitchen cabinet and refrigerator
Sharp knives were stored and locked in the kitchen drawers
All the disinfectants, cleaning solutions and poisons were stored and locked under the sink
Per tour of the backyard, there's shaded area with table and chairs for client to utilize.
No bars were observed on the windows or doors
No bodies of water were observed during the premises
Overall the outside area looked well maintained
Last Facility fire or earthquake drill was conducted on 09/16/22.
Per review of Staff records, Administrator and Facility manager do not have health screening and TB test result in File.
Administrator does not have any current updated training hours for HIV and TB

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1

Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the facility manager Teddy Idehen.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6

Document Has Been Signed on 03/02/2023 07:56 PM - It Cannot Be Edited

Created By: Christine Wong On 03/02/2023 at 02:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COVENANT CARE HOME	FACILITY NUMBER: 198603491
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, LPA observed the hot water at client bathroom was tested at 98.6 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/03/2023
	Plan of Correction
1 2 3 4	The administrator will adjust the hot water temperature immediately and send the 7 days hot water log to LPA by POC due date.

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:

David Sicairos

LICENSING EVALUATOR NAME:

Christine Wong

LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 03/02/2023 07:56 PM - It Cannot Be Edited

Created By: Christine Wong On 03/02/2023 at 02:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COVENANT CARE HOME	FACILITY NUMBER: 198603491
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, LPA observed the faucet in the client's bathroom was very loose which may posed a potenial health, safety or personal rights risk to person in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	The administrato will fix the faucet in the clients' bathroom and send the picture to LPA by POC due date.

Type B

Section Cited

CCR

80077.3(a)(3)(C)

Care for Clients who Lack Hazard Awareness or Impluse Control

(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed the last fire and earthquake drill was conducted on 09/16/2022 which posed a potenial health, safety or personal rights risk to person in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	The adminsitrator will conduct the fire and earthquake drill with client and staff and send the updated log to LPA by POC due date.

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:

David Sicairos

LICENSING EVALUATOR NAME:

Christine Wong

LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 03/02/2023 07:56 PM - It Cannot Be Edited

Created By: Christine Wong On 03/02/2023 at 02:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COVENANT CARE HOME	FACILITY NUMBER: 198603491
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

1562.5(a)

Other Provisions

(a) The director shall ensure that, within six months after obtaining licensure, an administrator of an adult residential facility and a program director of a social rehabilitation facility shall receive four hours of training on the needs of residents who may be infected with the human immunodeficiency virus (HIV), and on basic information about tuberculosis. Administrators and program directors shall attend update training sessions every two years after satisfactorily completing the initial training to ensure that information received on HIV and tuberculosis remains current. The training shall consist of three hours on HIV and one hour on tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA did not observe any updated HIV and TB training for administrator which posed a potential risk for clients in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	The adminsitrator will send the updated or current HIV and TB training by POC due date.

Section Cited

Administrator Qualifications and Duties


	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:

David Sicairos

LICENSING EVALUATOR NAME:

Christine Wong

LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 03/02/2023 07:56 PM - It Cannot Be Edited

Created By: Christine Wong On 03/02/2023 at 02:56 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COVENANT CARE HOME	FACILITY NUMBER: 198603491
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA did not observe the health screening form for adminsitrator and facility manager in their personnel record which posed a potenial health, safety or personal rights risk to person in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	The administrator will send the health screening form for administrator and facility manger to LPA by POC due date.

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA did not observe the TB test result for administrator and faciltiy manger in their personnel record which posed a potential health, safety or personal right risk to person in care.
	POC Due Date: 03/16/2023
	Plan of Correction
1 2 3 4	The administrator will send the TB test result for administrator and faciltiy manager to LPA by POC due date.

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:

David Sicairos

LICENSING EVALUATOR NAME:

Christine Wong

LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC809 (FAS) - (06/04)

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