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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603491
Report Date: 12/01/2022
Date Signed: 12/01/2022 03:48:43 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
11/30/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221130143831
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:
12/01/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Teddy IdehenTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility does not have enough staff to meet the needs of residents in care.
Facility does not have an adequate amount of food for residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint investigation to address the above allegations. LPA met with DSP Gradulupe Garcia and explained the reason of the visit and Shortly after, the house manger Teddy Idehen arrived and assisted with the visit.

The investigation consisted of the following: On today's visit, LPA Wong interviewed Staff#1 (S1), house manger in the facility, four clients (C1-C4) in the facility, staff#2 and administrator via telephone. LPA also interviewed client's regional center service coordiantor and the facility quality assurance via telephone.

The investigation revealed of the following: In regard to allegation "Faciltiy does not have enough staff to meet the needs of residents in care." LPA interviewed clients and reported staff are taking good care of them and they are able to assist their needs and they feel safe living there. LPA interviewed staff and all denied the allegation and reported they do have enough staffing in the faciltiy.
(Please See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
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 2
Control Number 28-AS-20221130143831
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: COVENANT CARE HOME
FACILITY NUMBER: 198603491
VISIT DATE: 12/01/2022
NARRATIVE
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The staff reported although the facility is a Level 4C medical home, the clients are easy to manage and they have no behaviors at all and they have been well taken care of. They usually have two staff during the busy hours like the early morning, evening and weekend. The administrator reported they even have extra or additional staffing in the facility.

In regard to the allegation "Facility does not have an adequate amount of food for residents in care. " LPA interviewed clients and reported they like the food in the facility and they can always get second plate if they needed. LPA interviewed staff and reported they always have plenty of food in the facility. They do grocery shopping every week. They would follow the facility menu but they would also modify depends on how clients like the food on that day. LPA also observed the 2 days perishable and 7 days non-perishable food supply in the kitchen which are sufficient and adequate.

Based on the LPA's observation, interviews conducted with client and staff and document reviewed, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted was with Teddy Idehen and a copy of this report and appeal right is being provided.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2