198603491-3-7-2025-28-AS-DKOI-DEJS97-20250307124017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603491
Report Date: 03/07/2025
Date Signed: 03/07/2025 12:40:44 PM

Document Has Been Signed on 03/07/2025 12:40 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	COVENANT CARE HOME		FACILITY NUMBER:	198603491
ADMINISTRATOR/ DIRECTOR:	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:	03/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Bundi Nyaga, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:50 PM

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	Licensing Program Analyst (LPA) Daniel Konishi conducted the unannounced Annual Inspection and met with Administrator Bundi Nyaga who allowed the entry of the facility and explained the reason of today's visit and will be using the Compliance And Regulatory Enforcement (CARE) Tools to inspect the facility. The facility is licensed for age range 18 through 59 and ambulatory only. The facility is vendorized with San Gabriel Pomona Regional Center. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical Services, Disaster Preparedness, and Emergency Intervention. Infection Control Plan: The facility has an updated Infection Control Plan in place. The staff practice hand washing and using gloves in the facility. Staff would clean and disinfect once a day and more often for high touched surfaces area. Facility has sufficient PPE supplies. Physical Plant and Environmental Safety: The facility is a single-story house and located in a residential neighborhood area. The facility includes kitchen, living room, staff work area, dining area, three client’s bedrooms, staff bathroom, one client bathroom, laundry room and an attached garage. Bedroom#1 has two beds, two chairs, two drawers, required furniture and beddings and sufficient lighting and closet space. Bedroom#2 and #3 has one bed, one chair, one night stand, one drawer, required furniture and bedding and sufficient closet space and lighting. The client bathroom is clean, sanitary and in a good working condition. Toilets and faucets are in working condition. The hot water temperature tested between 105.6 and 110.4 degrees F which is within the Title 22 regulation. All the kitchen appliances are working properly.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/07/2025 12:40 PM - It Cannot Be Edited

Created By: Daniel Konishi On 03/07/2025 at 12:14 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: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed Staff #1 (S1’s) valid first aid training is not in file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2025
	Plan of Correction
1 2 3 4	Administrator will send Staff #1 (S1's) valid first aid training to the LPA by the POC due date.

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
1 2 3 4	Based on record review, LPA observed Client #4 (C4’s) file did not have a Admission Agreement in file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2025
	Plan of Correction
1 2 3 4	Administrator will send a copy of Client #4 (C4's) Admission Agreement to the LPA by the 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:

Daniel Konishi

LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 03/07/2025 12:40 PM - It Cannot Be Edited

Created By: Daniel Konishi On 03/07/2025 at 12:14 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: 03/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.2(b)(1)(C)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed Client #2 (C2) and Client #3 (C3), Client #4 (C4’s) file did not have an updated Medical Assessment in filewhich poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2025
	Plan of Correction
1 2 3 4	Administrator will send Client #2 (C2), Client #3 (C3), and Client #4 (C4's) an updated medical assessment physician's report to the LPA by the 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:

Daniel Konishi

LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: COVENANT CARE HOME	FACILITY NUMBER: 198603491
	VISIT DATE: 03/07/2025

NARRATIVE

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Physical Plant and Environmental Safety [Cont.]: All the sharp knives are stored and locked in the kitchen drawer and all the cleaning supplies are stored and locked under the sink. The hallway light is on during nighttime so clients can have access to the non-private bathrooms. The extra personal hygiene products are stored in the hallway cabinet. The extra linen and towels are stored in the hallway cabinet next to the bathroom. Facility has a telephone service on the premises. The passageway, walkway and backyard are free of obstruction. Carbon monoxide detectors were tested and working properly. Fireplace is closed, secure, and inaccessible to clients. The fire extinguisher is in the dining room, fully charged and last inspected on 1/17/2025.

Operational Requirement: Facility Administrator is adhering to operational requirements. The facility would support client to participate community activities. The facility has a shaded area with table and chairs for client to utilize the outdoor activity.

Staffing: The facility has sufficient staffing in the facility. The NOC shift staff has the updated facility planned emergency procedure training.

Personnel Records/Staff Training: All the staff files are stored in the file cabinets. LPA reviewed five staff files which are over 18 years old with background check cleared and associated with the facility. LPA inspected five (5) staff files and they all have the required documents in files: Personnel Record, Health screening, TB Test result, updated first aid certificate Employee Rights, and required training hours. The facility administrator is Bundi Nyaga and his administrator certificate expiration date on 12/27/2026 and the administrator has the required and updated HIV and TB training certificate. However, based on record review, LPA observed Staff #1 (S1’s) valid first aid training is not in file.

Client's Right: The facility does not have any client with postural support at the present time. The facility would provide internet service with internet access device for client to communicate with their families or day program or their medical professional.

Food Service: The facility has ample supply for two days perishable and seven days non-perishable food supply in the facility. All the food in the facility are stored properly. Kitchen is kept clean. LPA observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: COVENANT CARE HOME	FACILITY NUMBER: 198603491
	VISIT DATE: 03/07/2025

NARRATIVE

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Client Records and Incident Reports: The client's files are stored in the file cabinet near the living room. LPA reviewed Client files for Client #1 (C1) through Client #4 (C4). Client files are maintained at the facility and have the following documents in their files - Face sheet, Physician's Report (including T.B and Ambulatory Status), Immunization records, Individual Program Plan (IPP), Functional Capabilities Assessment, Client Personal Belongings Inventory, and Clients Personal Rights. However, based on record review, Client #2 (C2) and Client #3 (C3), Client #4 (C4’s) file did not have an updated Medical Assessment in file. Based on record review, Client #4 (C4’s) file did not have a Admission Agreement in file.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for C1 through C4. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubble packed and delivered monthly. First aid kit was observed and has all required items. Facility staff provide transportation to medical and dental appointments.

Incidental Medical Services: The facility does not have any client with restricted health condition plan and they are not retaining any client with prohibited health condition.

Disaster Preparedness: The facility has an emergency disaster plan (LIC610D) updated on 4/02/2024. The last fire/disaster drill was conducted on 1/09/2025. The facility has two temporary alternative shelter location.

Emergency Intervention: The facility does not use any restraints on clients.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to Administrator, Bundi Nyaga.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC809 (FAS) - (06/04)

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