<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005962
Report Date: 04/29/2022
Date Signed: 05/05/2022 11:20:19 AM


Document Has Been Signed on 05/05/2022 11:20 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:A FAITHFUL HOME OF ANAHEIMFACILITY NUMBER:
306005962
ADMINISTRATOR:KHOLOMA, THERESAFACILITY TYPE:
740
ADDRESS:710 S. NEWCASTLE DRIVETELEPHONE:
(714) 699-1930
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 5DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Rudy IgnacioTIME COMPLETED:
04:00 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) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez met and was granted entry into the facility by Staff Sandy Lim and Staff Wilma Lee. Staff Lee confirmed there are currently no cases or exposures of COVID-19 within the facility. LPA was screened upon entry into the facility. Facility Manager Rudy Ignacio arrived shortly after.
LPA observed the required Department postings on COVID-19 precautions at entrance of facility and/or throughout the facility. There was a sign-in procedure in place and hand sanitizer for use. LPA observed staff were wearing face masks. The facility has an approved Mitigation Plan on file with CCLD. Five residents were present of which 3 are receiving Hospice care. LPA conducted a tour of the facility and made the following observations: LPA toured resident rooms, all rooms were within regulations. Restrooms observed contained hand washing soap, toilet paper and paper towels. The proper hand washing signs were up except in one bathroom. Facility has operating smoke and carbon monoxide detectors. Facility's Fire Extinguisher was charged. LPA observed a copy of Administrators Certificate which expired on 04/28/2023. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the residents regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan posted. Staff files were not available and staff are not associated to the facility. Four resident files were reviewed. LPA observed over-the-counter medication and a pre-poured pill box in unlocked cabinet in dining room, medication was also observed in 2 of 3 unlocked cabinets in hallway; only one cabinet was locked of the 3. Two bottles of medication were observed in the main refrigerator. Facility has 30 days supply of medications for the residents. One resident has 2 half bed rails on one side of the bed essentially creating a full bed rail. Per Facility Manager Ignacio resident is not receiving hospice services.

Based on observations made during today’s inspection, the following deficiencies will be cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed report Facility Manager and copy will be emailed.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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 3


Document Has Been Signed on 05/05/2022 11:20 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: A FAITHFUL HOME OF ANAHEIM
FACILITY NUMBER: 306005962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(g)(2)
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall;
(2) request a transfer of a criminal record clearance as specified in Section 87355(c) or...

This requirement is not met as evidenced by: LPA observed through record review and the use of the Guardian website that Staff 1 and Staff 2 are not associated to the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation in Guardian and interview with Administrator Kholoma, the facility did not comply with the section cited above in that 2 of 2 staff members were not associated to the facility. This poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty to be Assessed
POC Due Date: 05/02/2022
Plan of Correction
1
2
3
4
Administrator states the 2 staff members will be associated to the facility and all future staff will be associated to the facility prior to starting employment. LPA will review Guardian to verify the staff have been associated. Administrator to review section cited and self certify understanding and submit proof to LPA by 05/05/2022.
Type A
Section Cited
CCR
87465(h)(2)
(2) Centrally 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 centrally stored medication.

This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the facility did not comply with the section cited above. LPA observed over-the-counter medication (Melatonin, Extra Strength Acetaminphen, Anit-Diarrheal) and a pre poured pill box with one day medication in unlocked cabinet in dining room, prescription medication was also observed in 2 of 3 unlocked cabinets in hallway; only one cabinet was locked of the 3; two bottles of medication (Lorazapam Intensol Oral Concentrate, Mapap 500) were observed in the main refrigerator which poses an immediate health, safety risk to persons in care. (photos taken)
POC Due Date: 05/02/2022
Plan of Correction
1
2
3
4
Medication was secured away, cabinets were all locked during today's visit. Licensee to conduct in-service training to staff on section cited and submit proof to LPA Martinez by close of business day of 5/5/2022

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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/05/2022 11:20 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: A FAITHFUL HOME OF ANAHEIM
FACILITY NUMBER: 306005962

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review the licensee did not comply with the section cited above in that Resident 1 has (two) 2 half bed rails on one side of the bed essentially creating a full bed rail. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2022
Plan of Correction
1
2
3
4
Staff removed the two (2) half bed rails that made-up the full bed rail during today's visit. A physician order for half-bed rail, must be obtain prior to putting the half bed rail back.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3