<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005962
Report Date: 04/15/2021
Date Signed: 04/16/2021 09:50:22 AM

Document Has Been Signed on 04/16/2021 09:50 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A FAITHFUL HOME OF ANAHEIMFACILITY NUMBER:
306005962
ADMINISTRATOR:KHOLOMA, THERESAFACILITY TYPE:
740
ADDRESS:710 S. NEWCASTLE DRIVETELEPHONE:
(714) 300-8055
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 0DATE:
04/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Theresa KholomaTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Lydia Martinez contacted the facility via Zoom to conduct a Pre-Licensing inspection due to COVID-19 and pre-cautionary measures. LPA identified herself to Applicant Theresa Kholoma and discussed the purpose of the announced virtual call. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to CCL on 01/25/2021. There are 0 residents in care at the facility.

Facility is a one story house, with 7 bedrooms, and 4 bathrooms. LPA Martinez toured the interior and exterior premises. Fire Extinguisher was observed, mounted and charged. Smoke detectors, carbon monoxide detectors and auditory devices have been tested and are operational. There was a locked cabinet for medications in the dining area. Sharps are centrally stored and locked in a kitchen cabinet and toxins/cleaning supplies are properly locked and stored under the kitchen sink. Beds were made with appropriate linens. Furniture appears safe and adequate. Hot water temperature is tested by Administrator and is within regulatory requirements. The applicant has submitted a request for a Hospice Waiver. A plan to care for residents with Dementia was submitted. LPA observed all physical plant safeguards for Dementia to be within regulatory requirements. The Applicant states that she does not plan to advertise for Dementia. A Fire Clearance for a capacity of six, (five non ambulatory, one bedridden) residents was granted on 03/23/2021. The Applicant is an existing Licensee and has completed the Component III in the past. Component III will be waived during today’s visit. Applicant demonstrates and exhibits a clear concise comprehensive knowledge of medication protocols, documentation; and wound preventative care.

The Pre-Licensing evaluation has been completed. It appears this facility meets the requirements for licensure and a Hospice Waiver. The license and waiver will be granted upon completion of a final review and approval from the Application Specialist.

An exit interview was conducted with Applicant Kholoma via telephone. This report will be emailed and an electronic email read receipt confirms receiving of the report. Applicant agrees to sign the report and email back to LPA.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2021
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 1