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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004810
Report Date: 05/09/2022
Date Signed: 05/09/2022 02:49:41 PM


Document Has Been Signed on 05/09/2022 02:49 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
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:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:03 AM
MET WITH:House Manager Rudy IgnacioTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Celine De Perio and Albert Marin conducted an unannounced required annual inspection in this facility. Administrator Theresa Kholoma and House Manager (HM) Rudy Ignacio were informed about the presence of LPAs in the facility. HM Ignacio arrived in the facility. LPAs stated the purpose of the visit.

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

At 11:03 AM, LPAs De Perio and LPA Marin were granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure of the facility. LPAs observed five residents in care, while the sixth resident was out with a family member. LPAs observed two staff members on the floor. LPAs toured the interior and exterior portions of the facility with the House Manger, Rudy Ignacio. 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. Fire extinguisher was mounted and charged. Bathrooms were provided with grab bars, and hot water temperature was measured at 120 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. LPAs observed that knives and sharp kitchen tools were in a drawer that was not locked. LPAs observed disinfectant solutions and toxins located in a garage, however LPAs observed that garage door was unlocked and open.

At about 11:15 AM, LPAs observed 33 bottles of medication in Resident #1’s (R1) bedroom in plastic boxes, opened, sealed, with some expired medication. Per file review, R1 is unable to store own medication per physician report issued on March 24, 2021.

Continuation in Page 2.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306004810
VISIT DATE: 05/09/2022
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Continuation from Page 1

In a shared room occupied by Resident #2 and #3, LPAs noted offending odor in bedroom upon entrance at 11:25 AM.

Exterior portion of the facility had patio furniture observed in to be in good repair, with a shaded area provided. At 11:28 AM, LPAs observed locked padlocks on both exit gate in the backyard.

LPAs De Perio and Marin informed and reviewed the Coronavirus 2019 (COVID 19) mitigation plan of the facility with HM Ignacio. LPAs discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, deficiencies were observed; and citations were issued per Title 22 Division 6 of the California Code of Regulations.

LPAs De Perio and Marin conducted an exit interview with HM Ignacio. LPA explained the deficiencies, citations, and appeal rights to HM. Immediate civil penalty was assessed during this visit. Copies of this report, deficiency pages, civil penalty assessment, appeal rights, and cited regulations were left in the facility.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/09/2022 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306004810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202
87202 Fire Clearance
a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, facility did not maintain the fire clearance approved by County Fire Department. At 11:28 AM, LPAs observed locked padlocks on both backyard exit gates. Observation verified with House Manager. This poses an immediate threat on safety of residents in care.
POC Due Date: 05/23/2022
Plan of Correction
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House Manager directed staff to remove padlocks on both exit gates. Threat reduced. As plan of correction, facility will no longer apply padlocks on both exits. As proof of correction, Administrator will provde training on the regulation cited; and copy of the training will be provided to Community Care Licensing Division (CCLD) on or before 05/23/2022. Civil penalty was assessed.
Note: LPA provide copy of regulation for full reference.
Type A
Section Cited
CCR
87705(f)(1-2)
87705 Care of Persons with Dementia

This requirement is not met as evidenced by:
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
Deficient Practice Statement
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Based on observation, the facility did not maintain the knives, over-the-counter medication, cleaning supplies and disinfectants inaccessible to residents with dementia. LPAs observed knives in an open drawer, over-the-counter medication in resident's drawer, and cleaning supplies and disinfectants in a garage with open door. This poses an immediate threat in health and safety of residents in care.
POC Due Date: 05/23/2022
Plan of Correction
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House Manager instructed staff to keep knives in locked cabinet, take over-the-counter medication out of resident's drawer, and to always close and lock garage door. Threat reduced. As plan of correction, administrator will provide training to the regulations cited. Proof of correction will be submitted to Community Care Licensing Division on or before 05/23/2022.
Note: LPA provide copy of regulation for full reference.

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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/09/2022 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306004810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87365(h)(2)
87365(h)(2)
Incidental Medical and Dental Care
(2) Centerally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centerally stored medication.

This requirement was not met as evidence by:
Deficient Practice Statement
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Based on observation, interview and file review, the facility failed to keep the centrally stored medication in a safe and locked place that is not accessible to residents in care, other than employees responsible for the supervision of centrally stored medication. LPAs observed a total of 33 bottles of both sealed and unsealed medication in resident #1's room. This poses an immediate threat on the health and safety of the residents in care.
POC Due Date: 05/23/2022
Plan of Correction
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House Manager instructed to remove all medications from resident's room. Threat reduced. Administrator will provide training to staff on regulations cited. Proof of training will be submitted before or on 05/23/2022 to CCLD.
Note: LPA provide copy of regulation for full reference.
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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/09/2022 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306004810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
87625 Managed Incontinence
(3) Ensuring the continent residents are kept clean and dry and that the facility remains free of odors from incontience.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, facility failed to keep residents room clean and odor free from incontinence. LPAs noted a strong offending odor in a room shared by resident #2 and #3. This poses potential threat on health and safety of residents in care.
POC Due Date: 05/23/2022
Plan of Correction
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As Plan of Correction, House Manager will ensure that room is kept clean and odor free at all times. Proof of training on cited regulation will be provided to CCLD on or before 05/23/2022.

Note: LPAs provided copy of full regulation for reference.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5