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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005962
Report Date: 08/15/2023
Date Signed: 09/11/2023 12:27:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2022 and conducted by Evaluator Lydia Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220908145412
FACILITY NAME:A FAITHFUL HOME OF ANAHEIMFACILITY NUMBER:
306005962
ADMINISTRATOR:KHOLOMA, THERESAFACILITY TYPE:
740
ADDRESS:710 S. NEWCASTLE DRIVETELEPHONE:
(714) 699-1930
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY:6CENSUS: 6DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rudy Ignacio, House ManagerTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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- Staff refused to allow Resident back into the facility after a hospital visit
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of delivering findings for complaint investigation filed on 9/8/2022. LPA Martinez met with staff Luz Datu and Jonel Bojos. House Manager Rudy Ignacio was told of LPA's presence and arrived shortly after and LPA explained the purpose of the visit.

This agency has investigated the complaint alleging staff refused to allow resident back into the facility after a hospital visit. LPA Martinez reviewed facility documentation such as Resident 1’s (R1’s) facility file and West Anaheim Medical Center records dated from 8/16/2022 to 9/7/2022 for R1.

Information gathered during review of West Anaheim Medical Center records and interviews conducted reveal R1 was transported to the hospital via 911 emergency personnel on 8/16/2022 and admitted.

(see LIC9099c)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20220908145412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 ANAHEIM
FACILITY NUMBER: 306005962
VISIT DATE: 08/15/2023
NARRATIVE
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On 8/22/2022, hospital staff contacted Facility Administrator (AD) Theresa Kholoma via telephone to let her know R1 was ready to be discharged; “AD Kholoma told hospital staff that resident cannot be discharged back to the facility because she does not have the appropriate staff to take care of the patient.” On 9/7/2022, “witness called AD Kholoma and told her that R1 was ready to be discharged. AD Kholoma told the witness that the facility did not have room for the resident.” In an interview with AD Kholoma, she admitted she was contacted by hospital staff and was told R1 was ready to be discharged. AD stated she told hospital staff “she needed to reach out to R1’s family first.” Administrator also admitted to Licensing on 9/15/2022 that family abandoned R1, that facility is not being paid for R1’s care and that facility had 6 residents and no room for R1. Hospital records reviewed support that R1 stayed at the hospital from 8/22/2022 to 9/7/2022 due to R1 not being accepted back to the facility and the hospital could not find placement for R1. Hospital staff sought, found and relocated R1 to a Skilled Nursing Facility on 9/7/2022.

The preponderance of evidence standard has been met; therefore, the allegation that staff refused to allow resident back into the facility after a hospital visit is Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D. Report will be sent to email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20220908145412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 ANAHEIM
FACILITY NUMBER: 306005962
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2023
Section Cited
CCR
87224(a)
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Eviction Procedures- The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty days written notice to the resident is required...This requirement was not met as evidenced by:
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Licensee agrees to review regulation 87224 Eviction Procedures and provide proof of understanding that a 30 day notice should be issued before a resident is evicted by POC due date of 08/31/2023.
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Based on interviews and file review, the licensee admitted to not accepting R1 back to the facility from the hospital. The licensee did not serve R1 with a 30 day notice to evict the resident. This poses a potential risk to the health & safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3