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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602923
Report Date: 12/17/2024
Date Signed: 12/17/2024 11:01:10 AM

Document Has Been Signed on 12/17/2024 11:01 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A FAITHFUL HOME OF CERRITOSFACILITY NUMBER:
198602923
ADMINISTRATOR/
DIRECTOR:
THERESA KHOLOMAFACILITY TYPE:
740
ADDRESS:11213 AGNES STTELEPHONE:
(714) 300-8055
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 6DATE:
12/17/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Rudy Ignacio - House ManagerTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Plan of Correction visit for citation issued on 11/22/2024 on complaint control # 28-AS-20240919114357. LPA was greeted by Caregiver Silverio Madriga and the purpose for todays visit was explained. Shortly after House Manager Rudy Ignacio arrived to assist with the visit.

On 11/22/2024 the facility was issued a citation for the following:

80087(a) - 80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
    The requirement was not met as evidence by: During visit on 11/12/24 LPA toured R1's room and observed a large bubble in the ceiling of R1's room. 2 staff confirmed there had been a leak in room during rainy season, 2 residents also confirmed leak, R4's family member also confirmed leak. Although Administrator provided a roofing inspection that was conducted 11/14/24, this roof inspection did not disclose inspection of the noticeable bubble in ceiling of R1's bedroom. During visit on 11/22/24 LPA observed bubble on ceiling of R1's room still present, and new damage to R1's recess lighting.

Licensee failed to submit plan of correction to licensing by the POC due date of 12/09/2024.
As of today, DEFICIENCY IS NOT CLEARED. Civil Penalties were issued for period 12/10/2024 - 12/16/2024. Total of 7 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $700.00. A civil penalty of $100 per violation per day shall be assessed until the violation is corrected.

LPA explained the citation, civil penalty assessment, and appeal rights.

Exit interview was conducted with House Manager / Rudy Ignacio. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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