<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306006317
Report Date:
06/21/2024
Date Signed:
06/21/2024 02:40:31 PM
Document Has Been Signed on
06/21/2024 02:40 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 RO
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
FAITHFUL HOME OF ROSSMOOR, A
FACILITY NUMBER:
306006317
ADMINISTRATOR/
DIRECTOR:
MUNROE, ALICIA
FACILITY TYPE:
740
ADDRESS:
2851 BOSTONIAN DR
TELEPHONE:
(714) 300-8055
CITY:
ROSSMOOR
STATE:
CA
ZIP CODE:
90720
CAPACITY:
6
CENSUS:
5
DATE:
06/21/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:
Theresa Kholoma, Administrator (via telephone)
Rudy Ignacio, House Manager
TIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after explaining the purpose of the visit. Facility administrator Theresa Kholoma was notified by telephone. House manager Rudy Ignacio arrived later to assist.
During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one story home with 6 private bedrooms, one of which vacant, three bathrooms including one en-suite in addition to the facility's common living areas. A detached garage is present and used for storage as well as for the live-in care staff. The access door to the detached building is confirmed to be locked. The current license and facility sketch indicate that room #6 is for use by staff only. At the time of the visit, one resident is observed to be living in that room, indicating that the facility is out of compliance with the terms of the current license. A corresponding deficiency is cited on an attached form LIC809-D.
All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently five residents admitted to the facility, three of which are receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Combined smoke and carbon monoxide detectors tested operational. The two fire extinguishers present are observed to be fully charged, with up-to-date maintenance. Lysol and Clorox spray bottles are observed in a bathroom cabinet under the sink. Laundry detergent is also observed to be accessible. The magnetic lock for the drawer containing all sharp instruments is also observed to be broken and non-functional during the visit.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME
:
Sheila Santos
LICENSING EVALUATOR NAME
:
Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/21/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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:
FAITHFUL HOME OF ROSSMOOR, A
FACILITY NUMBER:
306006317
VISIT DATE:
06/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CONTINUED FROM FORM LIC809
Corresponding citations are also issued on attached forms LIC809-D. The medication central storage was observed to be secure and reviewed for accuracy during the visit. LPA reviewed five resident files and three staff files. Background clearance are verified. One staff association for a staff member assigned to the night shift appears to be missing. Corresponding citation issued.
Based on records reviewed, at least one resident death and one other resident's unscheduled hospitalization have failed to be reported to the Department, which fails to meet the Reporting Requirements present in Title 22 of the California Code of Regulations. Corresponding citation issued.
Based on the observations made during today’s inspection, four type A deficiencies and three type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations along with six advisory notes provided. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.
SUPERVISORS NAME
:
Sheila Santos
LICENSING EVALUATOR NAME
:
Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2024
LIC809
(FAS) - (06/04)
Page:
2
of
12
Document Has Been Signed on
06/21/2024 02:40 PM
- It Cannot Be Edited
Created By:
Kevin Saborit-Guasch
On
06/21/2024
at
01:46 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:
FAITHFUL HOME OF ROSSMOOR, A
FACILITY NUMBER:
306006317
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/21/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on facility visit and review of the terms of the current license, the licensee did not comply with the section cited above as room #6 is currently assigned to a faclity resident, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/22/2024
Plan of Correction
1
2
3
4
Licensee will move the resident from room #6 to the currently vacant room, as well as request an update of the fire clearance and submit an update of the license before resuming admission for potential residents assigned to room #6.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation conducted during the visit of the physical plan, the licensee did not comply with the section cited above as multiple spray bottles of cleaning solution and unsecured laundry supplies were observed. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/21/2024
Plan of Correction
1
2
3
4
Licensee removed the spray bottles and placed a lock on the laudry cabinet during the visit.
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:
Sheila Santos
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2024
LIC809
(FAS) - (06/04)
Page:
3
of
12
Document Has Been Signed on
06/21/2024 02:40 PM
- It Cannot Be Edited
Created By:
Kevin Saborit-Guasch
On
06/21/2024
at
01:47 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:
FAITHFUL HOME OF ROSSMOOR, A
FACILITY NUMBER:
306006317
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/21/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviewed, the licensee did not comply with the section cited above as one staff member covering the night shift was shown to not be associated to the facility in Guardian. This poses an immediate health, safety or personal rights risk to persons in care. Civil penalty assessed.
POC Due Date:
06/22/2024
Plan of Correction
1
2
3
4
Licensee will ensure the adequate association of all staff members to all their licensed locations before rotating staff from one facility to another. Proof of association to be provided to LPA before the plan of corrections due date.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation made during the facility visit, the licensee did not comply with the section cited above as the magnetic lock securing the drawer in which sharp items are stored is shown to be broken.This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/22/2024
Plan of Correction
1
2
3
4
Licensee will repair the lock and provide documentation of the repair to LPA before the plan of corrections due date.
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:
Sheila Santos
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2024
LIC809
(FAS) - (06/04)
Page:
4
of
12
Document Has Been Signed on
06/21/2024 02:40 PM
- It Cannot Be Edited
Created By:
Kevin Saborit-Guasch
On
06/21/2024
at
01:48 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:
FAITHFUL HOME OF ROSSMOOR, A
FACILITY NUMBER:
306006317
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/21/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on resident records reviewed during the facility visit, the licensee did not comply with the section cited above as one resident file was not shown to include a completed physician report. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/21/2024
Plan of Correction
1
2
3
4
Licensee will obtain a completed medical assessment for the resident in question and provide a copy to LPA before the plan of corrections due date.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation made during the facility visit, the licensee did not comply with the section cited above as one resident is receiving oxygen but no corresponding signage is in use throughout the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/21/2024
Plan of Correction
1
2
3
4
Licensee to ensure adequate signage is present whenever oxygen is in use and provide documentation thereof to LPA before the plan of corrections due date.
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:
Sheila Santos
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2024
LIC809
(FAS) - (06/04)
Page:
5
of
12
Document Has Been Signed on
06/21/2024 02:40 PM
- It Cannot Be Edited
Created By:
Kevin Saborit-Guasch
On
06/21/2024
at
02:11 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:
FAITHFUL HOME OF ROSSMOOR, A
FACILITY NUMBER:
306006317
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/21/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)(A)
(1) A written report shall be submitted to the licensing agency (...) within seven days of the occurrence of any of the events specified in (A) through (D) below. (...) (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, observation and record reviewed, the licensee did not comply with the section cited above as at least one death and one hospitalization were not reported to the Department. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/21/2024
Plan of Correction
1
2
3
4
Licensee will review its Reporting Requirements and provide update training to its administrative staff to ensure adequate reporting is done for future events. Evidence of the training will be provided to LPA before the plan of corrections due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Sheila Santos
LICENSING EVALUATOR NAME:
Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE:
06/21/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/21/2024
LIC809
(FAS) - (06/04)
Page:
12
of
12