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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004810
Report Date: 06/28/2024
Date Signed: 06/28/2024 11:13:17 AM


Document Has Been Signed on 06/28/2024 11:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 4DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Amelia Morales, House ManagerTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Amelia Morales, House Manager and Administrative Designee. During today’s visit, LPA met with Amelia Morales, House Manager since Administrator was out-of-town at time of visit.

The facility is a two-story building with an approved fire clearance of six non-ambulatory residents of which one may be bedridden and hospice is approved for six. The facility currently has a census of four residents in care. All residents reside on the first floor.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 128.9 and 130 degrees Fahrenheit and Caution Hot Water signs are posted in bathrooms until water temperatures are adjusted between 105 to 120 degrees Fahrenheit. All smoke detectors were operational. The fire extinguisher is charged and was serviced on August 23, 2023. The facility’s last fire drill was conducted on April 20, 2024. The PUB 475 poster posted is not the required 20" X 26" size. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medication appear to be being given as prescribed.

LPA reviewed four of four staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. The administrator has a current administrator certificate which expires on April 28, 2025.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: A FAITHFUL HOME
FACILITY NUMBER: 306004810
VISIT DATE: 06/28/2024
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The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations along with two technical violations.

An exit interview was conducted with Amelia Morales, House Manager and Administrative Designee and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D, LIC 9102-TV and Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 06/28/2024 11:13 AM - 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: A FAITHFUL HOME
FACILITY NUMBER: 306004810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Licensing Program Analyst file review, the licensee did not comply with the section cited above in three of four dementia residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2024
Plan of Correction
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Facility will obtain updated LIC 602 Physician Reports for two of four residents from medical providers for dementia residents.
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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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