A Faithful Home of Cerritos

Type of visit: Required - 1 Year

On 6/23/26, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to A Faithful Home of Cerritos. Upon arrival LPA was greeted by Direct Support Professional (DSP) Dominador Laguarda who contacted the House Manager, Rudy Ignacio. LPA explained the reason for the visit. This home is licensed to serve age range 60 and over. Six (6) non-ambulatory only. Hospice waiver for two (2). There were (6) residents in care during the time of this visit. The last emergency disaster/fire drill was conducted on 5/05/2026. The Administrator Certificate expires on 4/28/2027. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (0) staff files (House manager stated the files will have to be emailed to LPA), (6) resident files, and medications for (6) residents. LPA attempted to interview all 6 residents, 2 of which was able to communicate. During the visit 2 staff was interviewed. This home contains 5 bedrooms, 2 bathrooms, living room with non-working fireplac with cover, kitchen, dining room and an attached garage. LPA toured the physical plant with the DSP and observed all (5) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 117.0*F-118.8*F. The smoke detectors were battery operated, tested, and observed to be working properly. The carbon monoxide detector was located in the hallway, tested, and functioning properly. There were (1) fire extinguisher located in kitchen fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked in kitchen cabinet. The cleaning agents and toxins were locked in the garage. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home. (Report continued on LIC809C.) During file review LPA observed 2 out of 6 residents did not have a TB test on file. 2 staff files will be emailed to LPA along with 3 resident doctors’ orders for bedrails. The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for residents’ use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the residents. LPA also noted beds in the garage. According to staff they use it as a rest area. Exit interview conducted with Rudy Ignacio, House Manager, a copy of this report was provided, and Appeal rights given.the state’s words, verbatim · CDSS document, Jun 23, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Daniel Konishi conducted the unannounced required annual inspection. LPA met with the caregiver, Arney Manseguiao and the purpose for the visit was explained. Shortly after the House Manager, Rudy Ignacio arrived and LPA explained the purpose of the visit. This home is licensed to serve the age range 60 and over. Six (6) non-ambulatory only. Hospice waiver for six (6). The initial annual visit was conducted on 07/31/2025. During the initial visit the following six (6) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant Environmental Safety, Resident Rights-Information, Planned Activities, Food Services, and Disaster Preparedness. During today’s annual visit, the following six (6) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Operational Requirements, Staffing, Personnel Records-Training, Resident Records-Personnel Reports, Incidental Medical and Dental, and Resident with Special Health Needs. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation and maintains the required liability insurance in place. Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in the care and supervision of the residents in the case of an emergency. Personnel Records-Training: LPA observed four (4) staff files which include: health screening, TB test results, personnel records, criminal record clearance, current First-Aid/CPR/AED training, medication assistance, dementia, and other ongoing training are documented in personnel files. Administrator’s Certificate Expires on 04/28/2027. However, Staff #2 (S2’s) file did not have a health screening. Resident Records-Incident Reports: Resident files are kept in a secure location. LPA reviewed six (6) resident files which included the Face Sheet, Identification and Emergency Information, Physician’s Report, ambulatory status, TB test result, Pre-admission appraisal/Appraisal Needs & Services Plan, Preplacement appraisal, Admission Agreements, Personal Rights. Based on record review, LPA observed Resident #6 (R6’s) file did not have an updated medical assessment. Based on record review, LPA observed that Resident #2 (R2) and Resident #3 (R3’s) file has a physician’s report that has a Dementia diagnosis that is over a year old. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in a closet and are in their original containers. LPA reviewed six (6) residents’ medications and there were no issues observed. Residents with Special Health Needs: There are no bedridden or residents with postural support at this facility. There are no residents with prohibited and restricted health conditions. There are three (3) residents that receive hospice care. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the House Manager, Rudy Ignacio.the state’s words, verbatim · CDSS document, Aug 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted the required annual inspection. LPA arrived unannounced and was greeted by the caregiver, Arney Manseguiao and the purpose for today’s visit was explained. Shortly after the House Manager, Rudy Ignacio arrived and LPA explained the purpose of the visit. This home is licensed to serve the age range 60 and over. Six (6) non-ambulatory only. Hospice waiver for two (2). LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit, today’s visit and the initial visit and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are cleaning and disinfecting throughout the day. The facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Physical Plant & Environment Safety: LPA toured a one-story residential home that include a living room, dining area, kitchen, five (5) bedrooms, two (2) bathrooms, an attached garage with laundry, front yard and back yard. The five (5) residents’ bedrooms were checked by the LPA and closet/drawer space to accommodate each resident comfortably was available. The LPA observed all (5) resident bedrooms, containing required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and bathmat. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. Hygiene products are readily available for clients. The hot water temperature was tested and measured 110.5 degrees and 110.6 degrees, which is within the required range of 105-120 degrees F. Physical Plant & Environment Safety [Cont.]: The cleaning solutions and toxins are locked in the garage. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fireplace in the living room is secure and inaccessible to residents. There was (1) fire extinguisher located in kitchen fully charged. The last fire/disaster/earthquake drill was conducted on 5/25/2025. The backyard has a shaded seating area accessible for residents’ use. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Food Service: LPA toured the kitchen which appeared clean and the appliances and fixtures functional. The facility kitchen was observed to be clean at the time of inspection. There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are no clients with modified diets residing at this facility. Plates, cups and utensils are kept clean and stored properly. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least two (2) relocation sites. The last fire/disaster drill was conducted on 05/25/2025. Due to time constraints, LPA will return at a later date to complete the annual visit and six (6) CARE Tool domains. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. An exit interview was conducted and a copy of the report was provided to the House Manager, Rudy Ignacio.the state’s words, verbatim · CDSS document, Jul 31, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tena Herrera conducted a Case Management Visit-Deficiencies stemming from initial complaint investigation conducted on 11/22/24, complaint control # 28-AS-20240919114357. LPA Herrera met with Rudy Ignacio (House Manager) and explained the reason for visit. Case Management-Deficiencies findings: During complaint investigation dated 11/22/24, LPA observed a large bubble on the ceiling of R1’s room which usually indicates some sort of water damage. LPA interviewed 3 residents and 2 out of 3 confirmed that they have observed the leaks in R1’s room during the rainy season. LPA interviewed R4’s family member and they stated they have also witnessed the leak during the rainy season. LPA interviewed 3 staff and 2 out of 3 staff confirmed that during the rainy season there had been a leak in the room of R1. Due to LPA's observations and statements made by staff, residents and 1 residents family member there was sufficient evidence to confirm water was entering residents room during the rainy season. Citation will be issued and details can be found on the LIC809-D page. Exit interview held, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 27, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: LPA observed a large bubble on the ceiling of R1’s room, interviews with 2 out of 3 residents, 2 out of 3 staff and 1 family memeber confirmed that they have observed the leaks in R1’s room during the rainy season.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Administrator to submit a written plan to LPA via email explaining how facility will ensure that no water will enter residents room during rainy seasons.

Type of visit: POC

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Plan of Correction visit for citation issued on 11/22/2024 on complaint control # 28-AS-20240919114357. LPA was greeted by Caregiver Silverio Madriga and the purpose for todays visit was explained. Shortly after House Manager Rudy Ignacio arrived to assist with the visit. On 11/22/2024 the facility was issued a citation for the following: 80087(a) - 80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. The requirement was not met as evidence by: During visit on 11/12/24 LPA toured R1's room and observed a large bubble in the ceiling of R1's room. 2 staff confirmed there had been a leak in room during rainy season, 2 residents also confirmed leak, R4's family member also confirmed leak. Although Administrator provided a roofing inspection that was conducted 11/14/24, this roof inspection did not disclose inspection of the noticeable bubble in ceiling of R1's bedroom. During visit on 11/22/24 LPA observed bubble on ceiling of R1's room still present, and new damage to R1's recess lighting. Licensee failed to submit plan of correction to licensing by the POC due date of 12/09/2024. As of today, DEFICIENCY IS NOT CLEARED. Civil Penalties were issued for period 12/10/2024 - 12/16/2024. Total of 7 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $700.00. A civil penalty of $100 per violation per day shall be assessed until the violation is corrected. LPA explained the citation, civil penalty assessment, and appeal rights. Exit interview was conducted with House Manager / Rudy Ignacio. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 17, 2024

Allegation investigated: Facility is retaliating against the resident. Facility Rate increase is not following title 22 regulation.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent visit to deliver finding on the allegations listed above.Upon arrival LPA met with the House Manager Rudy Ignacio and explained the reason for the visit. The investigation consisted of the following: LPA Truman conducted initial visit on 9/24/24 during visit LPA toured the facility, requested a copy of the resident roster and staff roster via email, interviewed: 3 staff (S1-S3) and interviewed 3 residents (R1-R3). During visit conducted on 11/12/24 LPA Herrera toured the facility, interviewed 3 staff (S1-S3), interviewed 3 residents (R1-R3) and 1 residents family memeber. LPA reviewed files for R1 and obtaineed copies of their Admission Agreement, Face Sheet and Physician Report and requested for Administrator Teresa to email LPA copy of rent increase letter for R1 and roof inspecion report. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Facility is retaliating against the resident. It is alleged that facility is retaliating against R1 as it is believed that the rate increase has been implemented due to a replacement of broken furniture in R1’s room. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation, staff stated that they have never retaliated against a resident and haven’t witnessed any other staff retaliate against residents. Interview with Administrator Theresa revealed that the reason for the rate increase is due to inflation and rise in cost for healthcare needs which lead to a room rate increase. Administrator further confirmed that this rate increase is not a form of retaliation. LPA interviewed 3 residents and 1 family member, although 2 residents and 1 family member have assumptions that rate increase is due to retaliation, there was no evidence of this assumption. Allegation: Facility Rate increase is not following title 22 regulation. It is alleged that the facility did not provide resident with a 60 day notice of rate increase, which is the requirement per title 22 regulations. LPA reviewed rate increase letters that were provided by R1 and Administrator, each letter was dated September 1st 2024, however, per interview and email conversation with R1 several letters were provided to them with a letter given on September 7th 2024 that stated rent increase will begin in October. R1 confirmed that Administrator stated the increase would not be in October but in November, providing resident with the 60 day notice, R1 further confirmed that the rate change did not take effect in October and the payment for November was when the rate increase began. R1 is scheduled for payments on the 16th of each month, therefore, 60 days notice was provided to resident. LPA interviewed 2 Residents, R2 confirmed they have experienced a rate increase and were provided a 60 day notice, R3 stated they are not sure of any rate increase as their family handles their finances, interview with family member of R4 stated they have not experienced any rate increase. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation and stated that Administrator follows the regulation and believe 60 day notice is given to the residents when there is a change in rate. Based on statements and interviews conducted, a review of R1's files, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 28-AS-20240919114357

Allegation investigated: Facility roof is leaking.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent visit to deliver finding on the allegation listed above.Upon arrival LPA met with the House Manager Rudy Ignacio and explained the reason for the visit. The investigation consisted of the following: LPA Truman conducted initial visit on 9/24/24 during visit LPA toured the facility, requested a copy of the resident roster and staff roster via email, interviewed: 3 staff (S1-S3) and interviewed 3 residents (R1-R3). During visit conducted on 11/12/24 LPA Herrera toured the facility, interviewed 3 staff (S1-S3), interviewed 3 residents (R1-R3) and 1 residents family memeber. LPA reviewed files for R1 and obtaineed copies of their Admission Agreement, Face Sheet and Physician Report and requested for Administrator Teresa to email LPA copy of rent increase letter for R1 and roof inspecion report. (Continued on LIC9099-C) Substantiated Allegation: Facility roof is leaking. It is alleged that the roof in R1’s room has a leak in the ceiling. LPA toured R1’s room and observed a large bubble on the ceiling of R1’s room which usually indicates some sort of water damage. LPA interviewed 3 residents and 2 out of 3 confirmed that they have observed the leaks in R1’s room during the rainy season. LPA interviewed R4’s family member and they stated they have also witnessed the leak during the last rainy season. LPA interviewed 3 staff and 2 out of 3 staff confirmed that during the rainy season there had been a leak in the room of R1. Administrator Theresa stated that the facility has had a roof inspection done in which it was determined that the ceiling had no leaks. A copy of roof inspection dated 11/14/24 was provided to LPA via email by Administrator and it stated that there were no holes or openings seen in the attic area of the facility, however, there was no mention to the bubbling area on the ceiling of R1’s room. Based on LPA's observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC9099-D. Exit interview held, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 28-AS-20240919114357

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a) · Plan of correction due date: Dec 9, 2024

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidence by: During visit on 11/12/24 LPA toured R1's room and observed a large bubble in the ceiling of R1's room. 2 staff confirmed there had been a leak in room during rainy season, 2 residents also confirmed leak, R4's family member also confirmed leak. Although Administrator provided a roofing inspection that was conducted 11/14/24, this roof inspection did not disclose inspection of the noticeable bubble in ceiling of R1's bedroom. During visit on 11/22/24 LPA observed bubble on ceiling of R1's room still present, and new damage to R1's recess lighting.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: Administrator/Licensee to have a repair person who is knowledgeable in water damage and mold to inspect ceiling in R1's room. Copy of the inspection and any needed repairs to be provided and completed by POC due date.

Allegation investigated: Facility staff are not meeting resident's showering needs

**The purpose of the visit is to provide additional information not included on the citation issued on 10/17/24. The finding will remain the same.** On 10/17/24, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival, LPA met with House Manager (Rudy Ignacio) and explained the reason for the visit. LPA contacted and interviewed the Administrator (Teresa Kholoma) via phone. During today’s visit LPA toured the facility with the House Manager and took photos. LPA obtained a copy of the resident roster, staff roster and Resident #1 Admission Agreement. LPA requested a copy of R1’s physician’s report via email. LPA asked for a shower schedule, to which the House Manager stated they do not have a schedule. (Report continued on 9099c). Substantiated LPA interviewed: Administrator and a total of two (2) staff who shall be referred to as S1 and S2. LPA interviewed a total of 3 residents who shall be referred to as: R1 through R3. Due to Resident #4 through Resident #6 diagnosis LPA could not conduct interviews. LPA interviewed the responsible party for R1 and R4 who shall be referred to as Witness #1 and Witness #2 (W1 and W2). The investigation reveals the following: Regarding " Facility staff are not meeting resident's showering needs”. It is alleged that the facility placed a time limit on R1’s showers. According to R1 and W1, a meeting was held with the Administrator regarding R1 taking more than one (1) hour to the shower. The Administrator told R1 to start taking 40 minutes showers. R1 denied taking more than one (1) hour to shower. R1 stated they were also washing their face and taking care of their toileting needs. R1 and W1 further stated that there are times when staff are not in the bathroom when R1 is showering, and R1 felt it was unfair to include that in there “time limit”. R1 stated due to their unique health condition they do need a longer time in the shower. The Administrator stated they did not place a time limit, but came up with an agreement with the resident and their family. Based on resident interviews, it was determined that R2 does not take showers, but sponge baths. In the interview with R3, they stated that they were independent and conduct their own sponge baths without the assistance of staff. S1 stated they were not there during the meeting with family, but only one (1) resident takes a sponge bath, and the other residents are showered daily. S2 confirmed R1 not only takes showers, but also uses the toilet. S2 further confirmed leaving R1 in the bathroom for no more than 15 minutes whenever another resident needs assistance. LPA concluded that all residents do not require the same amount of time, and reviewed R1’s Physicians Report stating “keep perineal area clean and dry” due to medical condition. Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above Allegation is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D. Exit Interview Conducted with Administrator/ Appeal Rights Provided / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 28-AS-20241009132138

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Oct 24, 2024

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement was not met as evidenced by: Based on interviews R1 was unable to make the decison concerning how long they can use the bathroom. The bathroom time for R1 include showers, washing their face and having a bowel movement , which is potentially a health safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 22, 2024

Plan of correction: The licensee will ensure the resident can make their own choices. Staff training will be conducted regarding residents personal rights. A copy of the traing is due to LPA by POC due date.

Allegation investigated: Facility staff are not meeting resident's showering needs.

On 10/17/24, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to investigate the allegation listed above. Upon arrival, LPA met with House Manager (Rudy Ignacio) and explained the reason for the visit. LPA contacted and interviewed the Administrator (Teresa Kholoma) via phone. During today’s visit LPA toured the facility with the House Manager and took photos. LPA obtained a copy of the resident roster, staff roster and Resident #1 Admission Agreement. LPA requested a copy of R1’s physician’s report via email. LPA asked for a shower schedule, to which the House Manager stated they do not have a schedule. LPA interviewed: Administrator and a total of two (2) staff who shall be referred to as S1 and S2. LPA interviewed a total of 3 residents who shall be referred to as: R1 through R3. Due to Resident #4 through Resident #6 diagnosis LPA could not conduct interviews. LPA interviewed the responsible party for R1 and R4 who shall be referred to as Witness #1 and Witness #2 (W1 and W2). (Report continued on 9099c). Substantiated The investigation reveals the following: Regarding " Facility staff are not meeting resident's showering needs”. It is alleged that the facility placed a time limit on R1’s showers. According to R1 and W1, a meeting was held with the Administrator regarding R1 taking more than one (1) hour to the shower. The Administrator told R1 to start taking 40 minutes showers. R1 denied taking more than one (1) hour to shower. R1 stated they were also washing their face and taking care of their toileting needs. R1 and W1 further stated that there are times when staff are not in the bathroom when R1 is showering, and R1 felt it was unfair to include that in there “time limit”. R1 stated due to their unique health condition they do need a longer time in the shower. The Administrator stated they did not place a time limit, but came up with an agreement with the resident and their family. Based on resident interviews, it was determined that R2 does not take showers, but sponge baths. In the interview with R3, they stated that they were independent and conduct their own sponge baths without the assistance of staff. S1 stated they were not there during the meeting with family, but only one (1) resident takes a sponge bath, and the other residents are showered daily. S2 confirmed R1 not only takes showers, but also uses the toilet. S2 further confirmed leaving R1 in the bathroom for no more than 15 minutes whenever another resident needs assistance. LPA concluded that all residents do not require the same amount of time, and reviewed R1’s Physicians Report stating “keep perineal area clean and dry” due to medical condition. Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above Allegation is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D. Exit Interview Conducted with Administrator/ Appeal Rights Provided / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Oct 17, 2024 · control 28-AS-20241009132138

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Oct 24, 2024

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement was not met as evidenced by: Based on interviews R1 was unable to make the decison concerning their daily lives, which is potentially a health,which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2024

Plan of correction: The licensee will ensure the resident can make their own choices. Staff training will be conducted regarding residents personal rights. A copy of the traing is due to LPA by POC due date.

Allegation investigated: Staff did not ensure residents dresser was in good repair

On 9/5/24, Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit to investigate the allegation listed above. Upon arrival LPA met with Staff #1 (S1) and explained the reason for the visit. S1 contacted the Administrator (Teresa Kholoma). The House Manager (Rudy Ignacio) arrived at 03:10 p.m., and LPA explained the purpose of the visit. The Administrator arrived at 4:25 p.m. to assist with the visit. During today’s visit LPA toured the facility with the House manager. LPA requested a copy of the resident roster and staff roster via email. LPA took photos of the dresser in R1’s room. LPA interviewed: Administrator and a total of three (3) staff who shall be referred to as S1 through S3. LPA interviewed a total of 3 residents who shall be referred to as: R1 through R3. Due to Resident #4 through Resident #5 diagnosis LPA could not conduct interviews. The last resident (R6) was hospitalized at the time of the visit. (Report continued on 9099c). Substantiated The investigation reveals the following: Regarding " Staff did not ensure residents dresser was in good repair”. It is alleged that R1’s dresser is broken. During the visit LPA interviewed the administrator. The Administrator stated the dresser was fixed before but R1 add heavy items into the draw. 2 out of 3 staff confirmed the Administrators comment of the dresser being fixed and broke again. 1 out of 3 staff stated they are unsure about what is going on with the dresser. 1 out of 3 residents interviewed stated the dresser drops when pulling it open. LPA observed the drawer in full of documents and is broken. During the conversation with the Administrator, they stated they will replace the draw. Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D. Exit Interview Conducted with Administrator/ Appeal Rights Provided / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Sep 5, 2024 · control 28-AS-20240827084017

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 9, 2024

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in which the Licensee did not ensure R1's dresser is in good repair, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2024

Plan of correction: The facility shall ensure R1's dresser is in good repair at all times. Photo proof of the correction is due to the LPA by the POC due date.

Type of visit: Required - 1 Year

On 6/24/24 at 8:40 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to A Faithful Home of Cerritos. Upon arrival LPA was greeted by Direct Support Professional (DSP) Mark Anthony who contacted the House Manager, Rudy Ignacio. At 8:50 a.m. to assist with today's visit. This home is licensed to serve age range 60 and over. Six (6) non-ambulatory only. Hospice waiver for two (2). There were (6) residents in care during the time of this visit. The last emergency disaster/fire drill was conducted on 5/24/2024. The Administrator Certificate expires on 4/28/2025 #6034678740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (4) staff files, (6) resident files, and medications for (6) residents. LPA attempted to interview all 6 residents, 2 of which was able to communicate. LPA also spoke to a responsible party for 1 of the residents. During the visit 2 staff was interviewed. This home contains 5 bedrooms, 2 bathrooms, living room with non-working fireplace, kitchen, dining room and an attached garage. LPA toured the physical plant with the House Manager and observed all (5) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 119.6*F-120.0*F. The smoke detectors were battery operated, tested, and observed to be working properly. The carbon monoxide detector was located in the hallway, tested, and functioning properly. There were (1) fire extinguisher located in kitchen fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked in kitchen cabinet. The cleaning agents and toxins was locked in the garage. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home. (Report continued on LIC809C.) During file review LPA observed 5 out of 6 residents has dementia but there physician’s report has not been updated within the required year. 1 staff file review did not have the required TB test. The facility stated staff had the screen and will send to LPA by tomorrow. The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for resident’s use. A shed full of storage supplies was also observed in the back yard. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, toiletries, personal care supplies, and toxins and cleaning agents stored locked and inaccessible to the residents. Exit interview conducted with Rudy Ignacio, House Manager, a copy of this report was provided, and Appeal rights given.the state’s words, verbatim · CDSS document, Jun 24, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not meet resident’s care needs in a timely manner. Staff spoke in an inappropriate manner to resident.

On 3/4/24 at 10:24 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to deliver findings. Upon arrival LPA met with Staff #1 (S1) and explained the reason for the visit. S1 contacted the Administrator (Teresa Kholoma). The house manager (Rudy Ignacio) arrived at 11:30 a.m., and LPA explained the purpose of the visit. During visit on 2/20/2024, LPA toured the facility with Administrator. LPA requested resident roster and staff roster via email. LPA conducted file review and obtained copies of all resident’s emergency and identification paperwork and R1’s physician report via email. LPA conducted file review for S1. LPA also conducted file review for S1. LPA interviewed: Administrator and a total of two (2) staff who shall be referred to as S1 and S2. LPA interviewed a total of 3 residents who shall be referred to as: R1 through R3. Due to Resident #4 through Resident #6 diagnosis LPA could not conduct interviews. Report continued on 9099c Unsubstantiated Prior to the visit LPA conducted interviews with R4 and R5 responsible parties and shall be referred to as Witness #1 (W1) and witness #2 (W2). LPA attempted to contact R6 responsible party three times and left a voice mail. The investigation reveals the following: Regarding " Staff did not meet resident’s care needs in a timely manner”. It is alleged that staff S1 takes 1 ½ to 2 hours to respond to R1’s calls. During the visit LPA interviewed the administrator. The Administrator denied the allegation stating staff has responded to all residents’ calls in a timely manner. 2 out of 2 staff denied the allegation, stating they have always responded in a timely manner, and it takes them no more than 20 minutes. They further stated there are times the residents want them to come right away, and they are bathing another resident. 2 out of 3 residents denied the allegation, stating staff have always responded when they are called at a reasonable time frame. 1 out of 3 residents stated S1 complains when called, but since residents have a call button staff has responded timely. 2 out of 2 witnesses stated they have not observed staff not responding to residents when they are at the facility. The investigation reveals the following: Regarding " Staff spoke in an inappropriate manner to resident”. It is alleged that staff S1 complains about R1 taking too long to use the restroom. During the visit LPA interviewed the administrator. The Administrator denied the allegation stating that S1 is kind and have no issues. 2 out of 2 staff denied the allegation, stating they have always spoke appropriately to the residents. 2 out of 3 residents denied the allegation, stating staff has always treated them kindly. 1 out of 3 residents stated S1 complains when called and don’t like being rushed to use the restroom. 2 out of 2 witnesses stated they have not observed staff speaking inappropriately to the residents. Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Teresa Kholoma and a copy of this record provided.the state’s words, verbatim · CDSS document, Mar 4, 2024 · control 28-AS-20240214130214