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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004810
Report Date: 06/28/2021
Date Signed: 06/28/2021 10:00:34 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A FAITHFUL HOMEFACILITY NUMBER:
306004810
ADMINISTRATOR:THERESA KHOLOMAFACILITY TYPE:
740
ADDRESS:26642 SALAMANCA DRIVETELEPHONE:
(949) 382-2818
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Administrator Amelia Morales TIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Albert Marin conducted an unannounced required annual inspection in this facility. LPA met with House Manager (HM) Amelia Morales and stated the purpose of this visit.

The facility is licensed for capacity of six non-ambulatory of which 1 may be bedridden; and with hospice waiver for two. For this visit, there were two residents under hospice care.

At 9:00 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure of the facility. LPA observed six residents in care and two staff members on the floor. LPA toured the interior and exterior portions of the facility with HM. There were two private and two shared resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide and auditory exit alarms were observed to be operational. Bathrooms were provided with grab bars, and hot water was at 118 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. Exterior portion of the facility had patio furniture observed in to be in good repair. Exterior exit doors were self-closing and self-latching.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with HM Morales; and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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