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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006335
Report Date: 07/24/2026
Date Signed: 07/24/2026 02:29:59 PM

Document Has Been Signed on 07/24/2026 02:29 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:A FAITHFUL HOME OF HUNTINGTON BEACHFACILITY NUMBER:
306006335
ADMINISTRATOR/
DIRECTOR:		KHOLOMA, THERESAFACILITY TYPE:
740
ADDRESS:6192 KIMBERLY DRIVETELEPHONE:
(714) 300-8055
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 4DATE:
07/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Amelia Morales - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On July 24, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purposes of conducting a required 1-Year annual visit using the CARE Inspection Tool. LPA Bentley was greeted and granted entry into the facility by staff, after stating the reason for the visit. Administrator (AD) Theresa Kholoma was contacted by telephone and assisted with the visit. AD was unable to be present and designated Administrator Amelia Morales to sign the report. AD Morales has an Administrator certificate, which expires on October 22, 2027.

The facility is licensed to operate age 60 and over for six (6) non-ambulatory residents, with a Hospice waiver for six (6). The building is a single story structure located in a residential neighborhood, which consists of the following: four (4) resident bedrooms, two (2) bathrooms, living area, dining area, kitchen, an outdoor covered seating area, and an attached two car garage. Currently, There are currently four (4) resident on census and present. LPA Bentley toured the inside and outside of the physical plant with staff. All rooms were inspected and the facility was observed to be appropriately furnished at the time of visit. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Additional linens, comforters, and bath towels were adequately stocked and available. Bathrooms were found to be clean and operational with water temperatures measured between 114.9 and 119 degrees F. The kitchen was observed clean and there was a two-day supply of perishable and seven-day supply of non-perishable food available. Toxins, disinfectants, sharps, and medications were secured. The backyard was observed with a shaded seating area for residents and the facility has two exit gates that were operational. LPA observed one out of five stove burners non-operation and the facility plans to repair/replace it.
Evaluation Report Continues on LIC 809-C
Kevin Saborit-Guasch
Eboni Bentley
DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2026
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: A FAITHFUL HOME OF HUNTINGTON BEACH
FACILITY NUMBER: 306006335
VISIT DATE: 07/24/2026
NARRATIVE
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The smoke alarms and carbon monoxide detectors were operable. An emergency safety drill was last conducted on May 5, 2026 and are conducted quarterly. Emergency food, emergency water, and emergency supplies were observed. The facility has two (2) fire extinguishers that were charged, mounted, and last serviced on August 13, 2025. First aid kit is maintained and contains all the necessary elements. A working telephone (657-227-8120) remains available, however the facility does not have a device that can be used by residents for teleconference purposes. Liability Insurance is effective September 1, 2025 and expires on September 1, 2026.

LPA Bentley conducted an audit of four (4) resident files (R1-R4), four (4) staff files (S1-S4), and medication and medication administration records review. Interviews were conducted with staff and residents. The record review revealed that two staff members do not have a completed Health Screening Report (LIC503). Although, the resident Needs and Service Plans were completed, four out of four were observed with missing signatures.

Based on today’s observations, deficiencies are being cited as per Title 22, Division 6, Chapter 8 of the California Code of Regulations.

An exit interview was conducted with Administrators, and a copy of this report, LIC809-D, LIC811s, Technical Violations, and appeal rights were provided at the end of the visit.

NOTE: LPA called Administrator Theresa Kholoma and discussed the report and deficiencies.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/24/2026 02:29 PM - It Cannot Be Edited


Created By: Eboni Bentley On 07/24/2026 at 01:55 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: A FAITHFUL HOME OF HUNTINGTON BEACH
FACILITY NUMBER: 306006335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)

87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance
services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one out of five stove burners, which poses a potential health and safety risk to persons in care. LPA observed one out of five stove burners is non-operational and in need of repair.
POC Due Date: 07/31/2026
Plan of Correction
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Administrator stated stove top burner will be repaired/replaced to ensure all five burners are operational, and Administrator will submit proof to CCLD by POC due date via LPA email.
Type B
Section Cited
CCR
87412(a)(11)
(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: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, staff interview, and record review, the licensee did not comply with the section cited above in two of four staff records, which poses a potential health and safety risk to persons in care. A record review revealed that two staff members do not have a completed Health Screening Report (LIC503).
POC Due Date: 07/31/2026
Plan of Correction
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Administrator stated health screening will be obtained for staff and proof provided to LPA via email by POC 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.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2026


LIC809 (FAS) - (06/04)
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