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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006067
Report Date: 09/10/2024
Date Signed: 09/10/2024 01:19:07 PM

Document Has Been Signed on 09/10/2024 01:19 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:FAITH HOME CARE, LLCFACILITY NUMBER:
306006067
ADMINISTRATOR/
DIRECTOR:		TECSON, ALEXANDERFACILITY TYPE:
735
ADDRESS:2367 W HANSEN ST.TELEPHONE:
(714) 496-1732
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 4CENSUS: 4DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Purita Ramos- Administrator
Jannelle Silva- Care Staff		TIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year evaluation using the Care Inspection Tool. LPA Cho was greeted and granted entry by Client #4 (C4) through the exit gate. Staff #1 (S1) greeted LPA in the home. Administrator (Admin) Purita Ramos arrived on premise after dropping off one client at the day program. The Administrator's Certificate for Purita Ramos expires on April 21, 2025.

The facility is a two story home located in a residential neighborhood. Facility offers at a Service level 3 and is licensed to serve four (4) ambulatory clients. There are two clients in care during today's visit with two staff on duty.

LPA observed the facility to be clean and sanitary. Stairway light was not in good repair and the light was not working. The first floor consists of one client bedroom and bathroom. The second floor consists of three client bedrooms and one client bathroom. There is one primary bedroom and bathroom on the second floor occupied by a live-in staff. All common areas were inspected including the laundry room, storage room (on the second floor), and the attached two car garage which doubles as an office. The clients' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 109.4 and 118.4 degrees Fahrenheit. The indoor temperature was within a comfortable range. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed more than a two day supply of perishables and seven day supply of non-perishable food. LPA toured the outside grounds. LPA observed the outdoor passageway free of obstruction. The exit gate was self-closing and self-latching. LPA observed sufficient seating and shading. Facility maintains a fire extinguisher which was mounted, charged, and serviced on June 6, 2024. The smoke/carbon monoxide detectors were tested and operational.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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 7
Document Has Been Signed on 09/10/2024 01:19 PM - It Cannot Be Edited


Created By: Jessica Cho On 09/10/2024 at 12:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FAITH HOME CARE, LLC
FACILITY NUMBER: 306006067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, administrator did not ensure the health screening was completed in one out of two staff which poses a potential Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Administrator stated that the health screening (LIC503) will be completed for S1 and will be submitted to LPA via email by POC due date.
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on observation, interview, and record review, administrator did not ensure the physician's report was completed in two out of four clients which poses a potential Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Administrator stated that a medical assessment will be obtained for R1 and R3 and will be submitted to LPA via email by POC due date.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 09/10/2024 01:19 PM - It Cannot Be Edited


Created By: Jessica Cho On 09/10/2024 at 12:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FAITH HOME CARE, LLC
FACILITY NUMBER: 306006067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, administrator did not ensure the TB exam was complete for two out of four clients which poses a potential Health, Safety, or Personal Rights risk to person(s) in care.
POC Due Date: 09/27/2024
Plan of Correction
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Adminstrator stated that the TB test will be completed and results will be submitted to LPA via email by POC due date.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: FAITH HOME CARE, LLC
FACILITY NUMBER: 306006067
VISIT DATE: 09/10/2024
NARRATIVE
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LPA observed the emergency disaster supplies including food/water in the medication closet located in the living room. The first aid kit contains all necessary elements. Emergency evacuation drills are conducted evidenced by the emergency drill logs. A working facility telephone number, (714) 496-1732, which connects to the Administrator's cell phone remains available. Only three out of the four clients have their own personal cell phone. Administrator Ramos will ensure to activate the facility land line and update the facility telephone number with the Department.

During today's visit, LPA conducted an audit of four client files and two personnel files. Discrepancies were noted as records were incomplete and missing. Client interviews were not conducted during today's visit. An interview with the Administrator was conducted. Medications were audited for one client as three other clients are not prescribed medications at this time. No discrepancies noted. The Personal & Incidental (P&I) Funds were not audited as clients self-manage their own funds per Administrator.

The following were advised: to ensure client/personnel records are complete and organized, to obtain medical assessments for clients and staff and results for the Tuberculosis Tests (TB), to repair the light fixture in the stairway, to ensure completion of the Emergency Disaster Plan (LIC610D), and to update the facility telephone number.

Based on the observations made during today's visit, deficiencies are being cited as per Title 22, Division 6 of the California Code of Regulations. Technical Advisories are also being issued.

An exit interview was conducted with Administrator Purita Ramos and Staff Jannelle Silva, and a copy of this report including the LIC809Ds, LIC811s, and the appeal rights were provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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