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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005962
Report Date: 07/31/2024
Date Signed: 07/31/2024 03:22:03 PM

Document Has Been Signed on 07/31/2024 03:22 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: 6DATE:
07/31/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:26 PM
MET WITH:Sadie Jamli - CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:36 PM
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On 7/31/2024, LPA Dwayne Mason Jr. arrived at the facility unannounced. LPA was greeted and granted by Sadie Jamli, Caregiver. LPA met with facility staff and explained the nature of the visit.

On 7/30/2024, during the plan of corrections visit 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 between 105 and 120 degrees Fahrenheit. LPA also reviewed the water log created by the facility.

Based on today's inspection, the facility fulfilled the plan of correction. No deficiencies noted. LPA reviewed this report and provided a copy to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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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