A Faithful Home of Anaheim

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPAs) Nancy Guillen and Hanna Fuller made an unannounced visit to the facility for the purpose of conducting a health and safety check inspection on residents in care. LPAs were greeted and granted entry by staff. LPAs met with Administrator (AD) Theresa Kholoma and discussed the purpose of the visit. LPAs toured the facility and observed residents watching television and enjoying breakfast. The facility appears to be clean, safe and sanitary. LPAs observed all knives and toxins were locked in a kitchen cabinet and in locked cabinets in the garage . LPAs observed the medications to be in the locked medication cabinet in the hallway. LPAs observed the medications in the fridge to be in locked boxes and inaccessible to residents in care. All staff present are background cleared and associated to the facility. Based on today's observations, no deficiencies are being cited. An exit interview was conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Aug 17, 2026

Type of visit: POC

Licensing Program Analysts (LPAs) Nancy Guillen and Hanna Gough made an unannounced visit to the facility for the purpose of conducting a POC inspection visit to verify correction of citations issued during the annual visit conducted on June 9, 2026 and POC visit from June 17, 2026. LPAs arrived at the facility and were greeted at the door by caregiver and granted entry. LPA met with Administrator Theresa Kholoma and explained the nature of today’s visit. Based upon this inspection, LPA observed the following: *Deficiency cited under Title 22 Regulation 87555(b)(27) has been cleared. LPA observed the kitchen to be cleaned and a pest control service agreement has been entered with pest control service company TheBugMan for quarterly service. *Deficiency cited under Title 22 Regulation 87465(e) has been cleared. Doctor's orders for Over the Counter Medication has been provided and placed in resident file. *Deficiency cited under Title 22 Regulation 87465(h)(2) has not been cleared. LPAs observed accessible medications in the unlocked garage fridge, kitchen cabinet and a dining room drawer. LPAs had staff remove all medication and place in a locked medication cabinet. A Civil Penalty was assessed. *Deficiency cited under Title 22 Regulation 87309(a) has not been cleared. Kitchen knives were stored in an unlocked kitchen cabinet. A Civil Penalty was assessed. Based on today's visit citations have been cleared and notated with civil penalties assessed per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with clearance letters, LIC809D, LIC421F and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jul 14, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87309(a) · Plan of correction due date: Aug 4, 2026

87309(a) Except as specified in subsection (b), the licensee shall ensure that ...knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended ...This requirement is not met as evidenced by: Based on observation, the licensee did not ensure knives were inaccessible to clients in care which poses a potential health, safety, or personal rights risk to persons in care. Kitchen knives were stored in a kitchen cabinet and were observed to be unlocked.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: LPA observed staff lock kitchen knives in a locked kitchen cabinet. Licensee stated they will conduct an in-service training and send to LPA via email by POC due date. Civil Penalty was assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jul 15, 2026

(h) The following requirements shall apply... (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons... This requirement is not met as evidenced by: The licensee did not comply with the section cited above in LPAs observing accessible medications in the unlocked garage fridge, kitchen cabinet and a dining room drawer, this poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: LPAs observed staff lock medications that were found in the kitchen cabinet and dining room drawer. LPAs observed staff lock the garage door making the garage fridge inaccessible to residents in care. Licensee stated they will remove all cleaning supplies and place in a locked cabinet and Licensee also stated they will obtain a lock for the garage fridge. Licensee to conduct an in-service training and send to LPA by POC due date. Civil Penalty was assessed.

Type of visit: POC

Licensing Program Analyst (LPA) Nancy Guillen made an unannounced visit to the facility for the purpose of conducting a POC inspection visit to verify correction of citations issued during the annual visit conducted on June 9, 2026. LPA arrived at facility was greeted at the door by caregiver and granted entry. LPA met with House Manager(HM) and explained the nature of today’s visit. Based upon this inspection, LPA observed the following: *Deficiency cited under Title 22 Regulation 87555(b)(27) has not been cleared. LPA observed the kitchen still had remnants of dead roaches and roach feces in the kitchen cabinets that were missed and not cleaned. *Deficiency cited under Title 22 Regulation 87465(h)(2) has not been cleared. LPA had staff remove all medication on June 9, 2026 during annual inspection, however on today's visit there were four medications in the kitchen fridge accessible to residents in care. At 2:03 pm LPA observed glass cleaner and disinfectant spray in resident bathroom; a deficiency was cited on today's date. Continued on LIC 809C At 3:34pm LPA observed over the counter medication did not have a doctor's order for Resident 1 (R1). LPA informed (HM) on prior visit of the orders needed in order to administer medication, Per interview on today's visit, HM stated over the counter medications are currently still being administered without the doctor's orders; a deficiency was cited on today's date. An exit interview was conducted civil penalties were assessed and deficiencies are being cited. A copy of LIC 809 reports, deficiencies, civil assessments, and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jun 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(e) · Plan of correction due date: Jul 8, 2026

87465(e)For every prescription and nonprescription PRN medication ... there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication ...This requirement is not met as evidenced by: Based on observation and interview, the licensee did not ensure medications were prescribed before admnistering medication which poses a potential health, safety, or personal rights risk to persons in care. Bayer, vitamin D3 and melatonin for R1 do not have a doctor's order.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Licensee to receive doctor's orders before administering over the counter medication to resident. Orders to be sent to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87309(a) · Plan of correction due date: Jul 8, 2026

87309(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, ...and other similar items which could pose a danger to residents are in locked storage and are not left unattended ...This requirement is not met as evidenced by: Based on observation, the licensee did not ensure cleaning solutions were inaccessible to clients in care which poses a potential health, safety, or personal rights risk to persons in care. Glass cleaner and disinfectant spray were left unattanded in resident restroom.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Licensee to conduct in-service training in regards to regulation 87309(a). Licensee to send written log of staff attended and items discussed to LPA via email by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Nancy Guillen made an unannounced visit to the facility for the purpose of conducting a POC inspection visit to verify correction of citations issued during the annual visit conducted on June 9, 2026. LPA arrived at facility was greeted at the door by caregiver and granted entry. LPA met with House Manager(HM) and explained the nature of today’s visit. Based upon this inspection, LPA observed the following: *Deficiency cited under Title 22 Regulation 87555(b)(27) has not been cleared. LPA observed the kitchen still had remnants of dead roaches and roach feces in the kitchen cabinets that were missed and not cleaned. *Deficiency cited under Title 22 Regulation 87465(h)(2) has not been cleared. LPA had staff remove all medication on June 9, 2026 during annual inspection, however on today's visit there were four medications in the kitchen fridge accessible to residents in care. At 2:03 pm LPA observed glass cleaner and disinfectant spray in resident bathroom; a deficiency was cited on today's date. Continued on LIC 809C At 3:34pm LPA observed over the counter medication did not have a doctor's order for Resident 1 (R1). LPA informed (HM) on prior visit of the orders needed in order to administer medication, Per interview on today's visit, HM stated over the counter medications are currently still being administered without the doctor's orders; a deficiency was cited on today's date. An exit interview was conducted civil penalties were assessed and deficiencies are being cited. A copy of LIC 809 reports, deficiencies, civil assessments, and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jun 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(e) · Plan of correction due date: Jul 8, 2026

87465(e)For every prescription and nonprescription PRN medication ... there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication ...This requirement is not met as evidenced by: Based on observation and interview, the licensee did not ensure medications were prescribed before admnistering medication which poses a potential health, safety, or personal rights risk to persons in care. Bayer, vitamin D3 and melatonin for R1 do not have a doctor's order.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Licensee to receive doctor's orders before administering over the counter medication to resident. Orders to be sent to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87309(a) · Plan of correction due date: Jul 8, 2026

87309(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, ...and other similar items which could pose a danger to residents are in locked storage and are not left unattended ...This requirement is not met as evidenced by: Based on observation, the licensee did not ensure cleaning solutions were inaccessible to clients in care which poses a potential health, safety, or personal rights risk to persons in care. Glass cleaner and disinfectant spray were left unattanded in resident restroom.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: Licensee to conduct in-service training in regards to regulation 87309(a). Licensee to send written log of staff attended and items discussed to LPA via email by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by care provider Marietta Magahum after explaining the purpose of the visit. Licensee Rudy Ignacio was notified via telephone and later arrived to assist with the inspection. LPA observed the administrator certificate for Theresa Kholoma was current with an expiration date of April 28, 2027. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents, of which one may be bedridden, with a hospice waiver for six. The facility is a one-story home with six resident bedrooms, one staff bedroom, four bathrooms, and a garage. During the inspection, LPA and Licensee conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following: LPA observed a residents watching television in the living room and resting in their respective bedrooms. LPA observed six residents in care and two staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall in a hallway next to the entrance of the facility. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the hallway storage closet. LPA observed bathrooms were clean and equipped with grab bars and non skid floors. LPA observed all windows were appropriately screened. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 112.4 and 115.5 degrees Fahrenheit. LPA toured the outside of the facility and observed the backyard had a shaded sitting area with furniture for resident use. LPA observed passageways leading to facility exterior exits were being used for storage. Per licensee, items will be removed and placed in the garage. Continued LIC 809C LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with a service date of February August 13, 2025 and located by the kitchen counter. Gas stove, microwave, washer, and dryer were all inspected however the top right burner on gas stove was not operational and dishwasher was also observed to not be in working condition. LPA observed knives and sharps to be stored in a locked kitchen cabinet. Toxic chemicals, cleaning solutions, and disinfectants were observed to be stored in the garage. Medication cabinet was observed to be locked and centrally stored in hallway cabinet however, refrigerated medication was stored in kitchen refrigerator accessible to residents in care; a Deficiency was cited on this date. LPA observed six dead small roaches in kitchen cabinets and one small live roach that ran under the fridge; a Deficiency was cited on today's date. LPA observed the First Aid Kit had all the required components. LPA observed the facility conducted their last emergency disaster drill on May 5, 2026. LPA began review of the records. LPA reviewed five resident records. All the required documentation were present and current in the residents files reviewed. LPA reviewed two employee records. All employee’s present have a criminal record clearance and were associated to the facility. Based on the observations made during today’s inspection, deficiencies are being cited. An exit interview was conducted, and a copy of this report and appeal rights and Legionnaire’s Disease fact sheet was left at the facility.the state’s words, verbatim · CDSS document, Jun 9, 2026

Allegation investigated: Staff is physically abusive towards residents Staff yells at residents

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 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.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 22-AS-20251117091459

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Dec 5, 2025

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: 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.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 5, 2025

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. 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.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: 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.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a case management visit. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Amelia Morales and discussed the purpose of the visit. While investigating complaint # 22-AS-20251117091459, LPA did not observe a physicians report for Resident #1( R1). LPA inquired about the report to AD and AD informed LPA that R1 does not have a physicians report and that it will need to be requested. A deficiency is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report, LIC809D, LIC811, LIC602 and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Nov 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Dec 5, 2025

87458(a) Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement was not met as evidence by: LPA did not observe a medical assessment for R1 in their facility file. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: Licensee stated they will obtain medical assessment with proof of TB test and send to LPA by POC due date.

Allegation investigated: Staff yell at resident

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to investigation the above identified complaint allegation. LPA arrived at facility and was greeted at the door and granted entry receptionist. LPA spoke with Theresa Kholoma, Administrator, and explained the purpose of the visit. Findings are based upon this investigation which included facility file review, and interviews conducted. It is alleged that staff yell at residents. Interviews with 6 of 6 residents stated that they have not seen staff yelling at anyone, but they do speak loudly at times. Sometimes staff speak loudly because there are some residents that are hard of hearing, but they don’t recall seeing or hearing yelling at any of the residents. Based on the lack of information and lack of corroborating witness regarding allegation. LPA is unable to determine if the alleged violation occurred as reported. Continued on LIC809-C Unsubstantiated Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the Administrator and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 22-AS-20220202114410

Type of visit: POC

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit for the purpose of conducting a Plan of Correction inspection for six deficiencies issued on May 20, 2025 during the required annual inspection. LPA was greeted and granted entry by staff. LPA met with House Manager Rudy Ignacio and explained the purpose of the visit. LPA toured the facility to check that the deficiencies have been corrected. LPA observed the carbon monoxide detector operational at the facility, LPA observed the toxins and chemicals are locked and made inaccessible to residents in care, LPA observed the medication in the fridge is locked and made inaccessible to residents in care. LPA observed PRN medication lists for residents and CPR certifications for staff. LPA observed a work order request for Corky’s pest control to provide services to the facility by Friday June 6, 2025. Based on today’s observations five out of the six citations have been fulfilled with one in progress by the Plan of Correction due date of May 31, 2025 thus clearing the Type A deficiencies CCR 87309(a), 87465(h)(2), 87465(c)(1) and HSC 1569.311, 1569.618(c)(3). An interview was conducted with House Manager Rudy Ignacio and a copy of this report was provided at the facility.the state’s words, verbatim · CDSS document, Jun 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection and was greeted and granted entry by staff. LPA met with House Manager Rudy Ignacio and explained the nature of the visit. The facility currently has six residents in care. The facility is a one-story home with six resident bedrooms, four bathrooms, staff bedroom, kitchen, dining room, living room, backyard with patio and attached 2-car garage. LPA observed required departmental postings throughout the facility. LPA observed resident bedrooms to have all the required components and furnishings. LPA observed resident bathrooms to have toilet paper, paper towels and non-slip mats. LPA tested the water in resident bathrooms to be at 118.5-118.9 degrees Fahrenheit. LPA observed the knives to be locked and made inaccessible to residents in care. LPA observed bugs in the kitchen cabinets. LPA observed a fire extinguisher in the kitchen charged and with a service date of July 12, 2024. LPA observed the garage not locked and made accessible to residents in care. LPA observed toxins and chemicals accessible to residents in the unlocked garage. LPA observed medication in the garage fridge and made accessible to residents in care. LPA observed the centrally stored medication to be locked and made inaccessible to residents in care. LPA observed the backyard to be free of obstructions. LPA observed a shaded seating area for resident use. LPA tested fire detectors and they were found to be operational. LPA observed no operational carbon monoxide detector. LPA observed incomplete staff files. LPA observed resident files and no discrepancies were observed. LPA observed the last fire drill conducted on May 25, 2025. LPA observed resident medication and 6 out of 6 residents did not have prescriptions for over the counter medication. All staff present are fingerprinted and associated to the facility. Continue on 809-C Based on todays observations, citations are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with House Manager Rudy Ignacio and a copy of this report along with 809-D pages, 858, 859 and appeal rights were given at the time of inspection.the state’s words, verbatim · CDSS document, May 30, 2025

Type of visit: POC

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.the state’s words, verbatim · CDSS document, Jul 31, 2024

Type of visit: POC

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.the state’s words, verbatim · CDSS document, Jul 30, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jul 31, 2024

(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 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.the state’s words, verbatim · CDSS document, Jul 30, 2024

Plan of correction: 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by House Manager Rudy Ignacio. LPA explained the purpose of the inspection.. The facility is a one-story home with six resident bedrooms, four bathrooms, kitchen, dining room, living room, backyard with patio and attached 2-car garage. Facility appears clean, safe and sanitary. LPA noted residents were lounging in their own rooms or the living room. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water initially measured above 120 degrees F. A deficiency is being issued. House Manager adjusted water heater resulting in hot water measuring between 105 and 120 degrees F. LPA observed facility has emergency food and water supply. LPA observed the fire extinguisher was last serviced on August 4, 2023. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in cabinets in the hallway. The backyard has a shaded sitting/lounging area. Exit gate is unlocked and self latching. LPA observed exit gate to be unobstructed. LPA reviewed three resident files and three staff files. LPA also reviewed medication for three residents. LPA interviewed one staff and three residents. LPA observed PUB 475 to be printed on 8.5" x 11" paper. LPA issued a Technical Violation and advised facility to print PUB 475 "See Something, Say Something" poster on 20" x 26" paper. Based on Title 22 Division 6 of the California Code of Regulations, one deficiency is being issued based on today's inspection. An exit interview was conducted and a copy of this report was provided to the facilitythe state’s words, verbatim · CDSS document, Jun 20, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.