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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603328
Report Date: 05/11/2026
Date Signed: 05/11/2026 02:54:29 PM

Document Has Been Signed on 05/11/2026 02:54 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A FAITHFUL HOME OF COVINAFACILITY NUMBER:
198603328
ADMINISTRATOR/
DIRECTOR:		DUONG, THANGFACILITY TYPE:
740
ADDRESS:1084 W GROVECENTER ST.TELEPHONE:
(626) 244-9999
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 6CENSUS: 4DATE:
05/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Glem Oriemo, Lead CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced annual inspection visit. LPA met with Glen Oriemo , Lead Caregiver. Administrator was not available to join today. The facility is licensed to serve 6 non-ambulatory residents (age range from 60 years old and over), including 1 bedridden. Facility has hospice care waiver for 4 residents. The annual fees were current. LPA explained the purpose of today's visit and the inspection to the administrator via telephone, Caregiver Oriemo assisted with the facility tour.

During the visit, Care tools, staff/resident interviews and physical plant were conducted; food supply, staff/residents files and medications were reviewed.

The facility is a single-story home located in a residential neighborhood consisting of 6 residents bedrooms, 2 bathrooms, a living room, a dining area, kitchen, laundry area in the garage, a garage, and an outdoor activity area at the backyard. The yard has a shaded area and free of debris/ hazard. Bathrooms are clean and operational. Sufficient supply of 2-day perishable and 7-day non-perishable foods. Adequate linen and personal hygiene supply. Smoke detectors are combined with carbon monoxide detectors and are operable and in compliance.
All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, and lighting. The facility has one (1) fire extinguisher that is fully charged in kitchen. Cleaning supplies and toxic substances are inaccessible locked in hallway closet. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. There are no firearms or weapons stored at the facility The resident bathrooms have the required grab-bars and non-skid mats. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F.
Continued on 809C...................
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2026
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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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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: A FAITHFUL HOME OF COVINA
FACILITY NUMBER: 198603328
VISIT DATE: 05/11/2026
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The common areas include the living room and dining area are clean and have the required furniture. The facility does not have a swimming pool or large body of water. There is a shaded seating area for the residents in back yard. Passageways and exits are free of obstruction.
Staff files were reviewed and included Criminal clearance record, and health screening with TB, all staff have a valid CPR/First Aid certificate. Four (4) resident files were reviewed and included physicians report, TB clearance, and appraisal needs and service plans. Last fire/earthquake drill was conducted on04/13/2026. Infectious control plan was reviewed. Disaster plan was reviewed on 05/02/2026. Two (2) staff and three (3) residents were interviewed. Resident medications were reviewed. Medications are centrally stored and locked MAR log is used.
The last Fire/ Emergency Drill was conducted on 04/26/2026. Auditory devices are operable. Administrator certificate is current and expires on 02/06/2027.

No deficiencies cited per California Code of Regulations, Title 22, Division 6.
Exit conference is conducted. Report LIC 809 and 809C is discussed and provided to Lead caregiver, Glen Oriemo.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
LIC809 (FAS) - (06/04)
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