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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603491
Report Date: 03/07/2023
Date Signed: 03/07/2023 05:26:45 PM

Document Has Been Signed on 03/07/2023 05:26 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 HOMEFACILITY NUMBER:
198603491
ADMINISTRATOR:AMANYA, HERBERT BAGOROFACILITY TYPE:
735
ADDRESS:2027 SHAMWOOD STTELEPHONE:
(818) 571-2247
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
03/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Teddy Idehen TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted an Annual/Required visit by using the Compliance And Regulatory Enforcement Tools on 3/2/2023 but due to time restrains and LPA has returned on today's date 3/7/2023 to finish the remaining five (5) domaints. LPA met with Facility Manager Teddy Idehen who allowed entry into the facility and assisted with the visit; as Administrator Herbert Amanya was unavailable at the time of this visit.

On today's date, LPA inspected the five (5) domain include: Client's Right Information, Client's Record-Incident Reports, health related services, Incidental Medical Services, Emergency Intervention and Disaster Preparedness.
  • Per review of Client's record and LPA did not observe an admission agreement for Client#1-#3
  • Per review of residents' medication, LPA observed Client#4 (C4) medication for Docusate Sodium 100mg one capsule by mouth 2x daily but staff only administered once daily for client
  • Per review of Emergency and Disaster Plan LIC610D , the facility has been updated the form on 03/07/2013 and its placed on the facility board near the entrance.
  • Per review of Staff record, LPA observed the last staff training for emergency and disaster preparedness was dated on 2020.


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

Exit interview was conducted, Appeals Rights discussed and a copy was given to the Facility Manager Teddy Idehen
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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 3
Document Has Been Signed on 03/07/2023 05:26 PM - It Cannot Be Edited


Created By: Christine Wong On 03/07/2023 at 03:24 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: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, LPA observed Client#4's medication- Docusate Sodium 100ng one capsule by mouth twice daily but Client#4 only take once daily at night which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2023
Plan of Correction
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Administrator will ensure to follow doctor order for client's medication. The administrator will contact the doctor or the pharamcy ensure what's the doctor order for Client#4 medication. And will send the updated information to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 03/07/2023 05:26 PM - It Cannot Be Edited


Created By: Christine Wong On 03/07/2023 at 03:24 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: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on recorded review, LPA obsered Client#1 to #3 do not have admission agreement in client's record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2023
Plan of Correction
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The administrator will ensure each client should have written admission agreentment in each clients' files. The administrator will send the copy of admission agreement to LPA by POC due date
Type B
Section Cited
HSC
1565(b)
Other Provisions
(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA did not observe staft have annual training for emergency and disaster and last one was dated in 2020 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2023
Plan of Correction
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The administrator will ensure each staff shall have training on the emergency and disaster upon hire and annually. The adminsitrato will send the updated staff training log for emergency and disaster 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: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
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