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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005962
Report Date: 12/04/2025
Date Signed: 12/04/2025 12:44:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/17/2025 and conducted by Evaluator Hanna Gough
COMPLAINT CONTROL NUMBER: 22-AS-20251117091459
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:
12/04/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Theresa KholomaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff is physically abusive towards residents
Staff yells at residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to investigate the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Theresa Kholoma and discussed the purpose of the visit.
The investigation into the facility allegations of staff is physically abusive towards residents and staff yells at residents revealed the following. LPA observed a video that was sent to the Department of Staff #1(S1), Resident #1(R1) and Resident #2(R2) sitting in front of the television. LPA observed that S1 was yelling at R1 to “Move” repeatedly, but R1 was trapped in the corner between the couch and R2s chair. When R1 attempted to move R2 back, S1 started yelling at R1 as well as take their shoe off and hold it in the air in a threatening manner towards R1. LPA observed S1 repeating what R1 was saying in a demeaning tone. S1 is observed to be swinging their leg in a kicking motion but it was unclear if they made contact with either resident with their leg or foot. R2 stated that S1 was “Going to get in trouble”, when LPA observed S1 hit R2 on the thigh in the video. R2 started to cry and the video ended.
Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
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-20251117091459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: A FAITHFUL HOME OF ANAHEIM
FACILITY NUMBER: 306005962
VISIT DATE: 12/04/2025
NARRATIVE
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LPA interviewed six of six residents and four of six residents did not respond to LPAs inquiries. One of six residents informed LPA that they are not aware of any incidents of abuse. One of six residents informed LPA they have seen S1 yell at and hit residents in care.

LPA did not observe any visible bruising on R2s arms or legs.

LPA interviewed three of four staff. Two of four staff informed LPA that they started at the facility on Monday with one just covering for the Administrator while they were on vacation. One of four staff informed LPA that they were not aware of the incident that occurred between S1, R1 and R2.

Four of Four staff informed LPA that S1 was terminated and their last day working at the facility was November 17, 2025, and that they had not been back. One of four staff informed LPA that they were told that an incident with verbal abuse had occurred at the facility but were unaware of anything physical. LPA showed staff the video to staff and one of four staff informed LPA that the same video was shown to the house manager and licensee. One of four staff informed LPA that they observed a video and observed that S1 was holding their shoe in the air in an intimidating manner but did not observe S1 yelling or hitting residents in care.

Based on observations made and information gathered during the investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC9099D.

An exit interview was conducted and a copy of this report, LIC9099D, LIC811 and appeal rights were left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20251117091459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 12/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) Personal Rights of Residents in All Facilities
To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by:
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Licensee stated they terminated S1 and will provide in service trainings for staff on topics such as yelling and mocking at residents and send proof to LPA by POC due date.
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LPA observed a video where S1 yelled at and repeated what residents were saying in a demeaning tone. This poses an immediate health, safety and personal rights risk to residents in care.
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Request Denied
Type A
12/05/2025
Section Cited
CCR
87468.1(a)(3)
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87468.1(a)(3) Personal Rights of Residents in All Facilities
To be free from punishment, humiliation, intimidation, abuse or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating sleeping, or elimination.
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Licensee stated they terminated S1 and will provide in service trainings for staff on topics of intimidation and physical abuse and send proof to LPA by POC due date.
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This requirement was not met as evidence by: LPA observed a video where S1 was seen intimidating R1 with a shoe and hit R2 on the thigh. This poses an immediate health, safety and personal rights risk to 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: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3