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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602923
Report Date: 11/22/2024
Date Signed: 11/22/2024 01:47:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2024 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240919114357
FACILITY NAME:A FAITHFUL HOME OF CERRITOSFACILITY NUMBER:
198602923
ADMINISTRATOR:THERESA KHOLOMAFACILITY TYPE:
740
ADDRESS:11213 AGNES STTELEPHONE:
(714) 300-8055
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY:6CENSUS: 6DATE:
11/22/2024
UNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Rudy Ignacio - House ManagerTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is retaliating against the resident.
Facility Rate increase is not following title 22 regulation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent visit to deliver finding on the allegations listed above.Upon arrival LPA met with the House Manager Rudy Ignacio and explained the reason for the visit.

The investigation consisted of the following:
LPA Truman conducted initial visit on 9/24/24 during visit LPA toured the facility, requested a copy of the resident roster and staff roster via email, interviewed: 3 staff (S1-S3) and interviewed 3 residents (R1-R3).
During visit conducted on 11/12/24 LPA Herrera toured the facility, interviewed 3 staff (S1-S3), interviewed 3 residents (R1-R3) and 1 residents family memeber. LPA reviewed files for R1 and obtaineed copies of their Admission Agreement, Face Sheet and Physician Report and requested for Administrator Teresa to email LPA copy of rent increase letter for R1 and roof inspecion report.
(Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 28-AS-20240919114357
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A FAITHFUL HOME OF CERRITOS
FACILITY NUMBER: 198602923
VISIT DATE: 11/22/2024
NARRATIVE
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The investigation revealed the following:
Allegation: Facility is retaliating against the resident.
It is alleged that facility is retaliating against R1 as it is believed that the rate increase has been implemented due to a replacement of broken furniture in R1’s room. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation, staff stated that they have never retaliated against a resident and haven’t witnessed any other staff retaliate against residents. Interview with Administrator Theresa revealed that the reason for the rate increase is due to inflation and rise in cost for healthcare needs which lead to a room rate increase. Administrator further confirmed that this rate increase is not a form of retaliation. LPA interviewed 3 residents and 1 family member, although 2 residents and 1 family member have assumptions that rate increase is due to retaliation, there was no evidence of this assumption.

Allegation: Facility Rate increase is not following title 22 regulation.
It is alleged that the facility did not provide resident with a 60 day notice of rate increase, which is the requirement per title 22 regulations. LPA reviewed rate increase letters that were provided by R1 and Administrator, each letter was dated September 1st 2024, however, per interview and email conversation with R1 several letters were provided to them with a letter given on September 7th 2024 that stated rent increase will begin in October. R1 confirmed that Administrator stated the increase would not be in October but in November, providing resident with the 60 day notice, R1 further confirmed that the rate change did not take effect in October and the payment for November was when the rate increase began. R1 is scheduled for payments on the 16th of each month, therefore, 60 days notice was provided to resident. LPA interviewed 2 Residents, R2 confirmed they have experienced a rate increase and were provided a 60 day notice, R3 stated they are not sure of any rate increase as their family handles their finances, interview with family member of R4 stated they have not experienced any rate increase. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation and stated that Administrator follows the regulation and believe 60 day notice is given to the residents when there is a change in rate.

Based on statements and interviews conducted, a review of R1's files, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
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