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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005962
Report Date: 07/30/2024
Date Signed: 07/30/2024 10:19:44 AM

Document Has Been Signed on 07/30/2024 10:19 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
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: 6DATE:
07/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:48 AM
MET WITH:Rudy Ignacio - House ManagerTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
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On 7/30/2024, LPA Dwayne Mason Jr. arrived at the facility unannounced. LPA was greeted and granted by Sadie Jamli, Caregiver. LPA met with House Manager, Rudy Ignacio and explained the nature of the visit.

On 6/20/2024, during the annual inspection conducted by the LPA, hot water in resident bathrooms was measured as being over 120 degrees Fahrenheit. LPA issued a citation.

LPA measured the hot water in the four bathrooms at the facility. Water in bathrooms measured over 120 degrees Fahrenheit. LPA also did not receive a documented water log from the facility.

Based on today's inspection, the facility did not fulfill the plan of correction. A deficiency is being issued. LPA reviewed this report with House Manager. LPA provided a copy of this report, deficiency page and appeal rights to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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 07/30/2024 10:19 AM - It Cannot Be Edited


Created By: Dwayne L Mason On 07/30/2024 at 10:04 AM
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: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2024
Section Cited
CCR
87303(e)(2)

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(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
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House Manager stated the facility will create a water log to measure the hot water in all resident bathrooms and adjust hot water to be within 105 and 120 degrees by the assigned POC due date of 7/31/2024.
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attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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.
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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: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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