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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005962
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:01:04 PM

Document Has Been Signed on 06/20/2024 04:01 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:A FAITHFUL HOME OF ANAHEIMFACILITY NUMBER:
306005962
ADMINISTRATOR/
DIRECTOR:
KHOLOMA, THERESAFACILITY TYPE:
740
ADDRESS:710 S. NEWCASTLE DRIVETELEPHONE:
(714) 699-1930
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Rudy Ignacio - House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by House Manager Rudy Ignacio. LPA explained the purpose of the inspection..

The facility is a one-story home with six resident bedrooms, four bathrooms, kitchen, dining room, living room, backyard with patio and attached 2-car garage. Facility appears clean, safe and sanitary. LPA noted residents were lounging in their own rooms or the living room.

All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water initially measured above 120 degrees F. A deficiency is being issued. House Manager adjusted water heater resulting in hot water measuring between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was last serviced on August 4, 2023. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in cabinets in the hallway. The backyard has a shaded sitting/lounging area. Exit gate is unlocked and self latching. LPA observed exit gate to be unobstructed. LPA reviewed three resident files and three staff files. LPA also reviewed medication for three residents. LPA interviewed one staff and three residents. LPA observed PUB 475 to be printed on 8.5" x 11" paper. LPA issued a Technical Violation and advised facility to print PUB 475 "See Something, Say Something" poster on 20" x 26" paper.

Based on Title 22 Division 6 of the California Code of Regulations, one deficiency is being issued based on today's inspection. An exit interview was conducted and a copy of this report was provided to the facility

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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Document Has Been Signed on 06/20/2024 04:01 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 06/20/2024 at 03:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to hot water in resident bathrooms measuring over 120 F degrees which poses an immediate safety risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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House Manager stated the facility will maintain a water log to measure the hot water in all resident bathrooms. House Manager stated they will email the water log to LPA by the assigned POC due date of 7/11/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
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