A Faithful Home of Rossmoor

Type of visit: Required - 1 Year

On June 29, 2026, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. House Manager Rudy Ignacio arrived shortly after and was available to assist with the facility inspection. The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for six (6) residents. Currently, there are three (3) Hospice residents present during today’s visit. This is a single story with detached garage facility. The facility has six bedrooms and three bathrooms. LPA conducted a tour of the physical plant accompanied by Staff and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 117.3 to 118.2 degrees F. A comfortable temperature of 75 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning toxins and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has two fire extinguishers which was mounted and fully charged. CONTINUED ON 809C A review of the Medication Records Administration (MAR) was observed and LPA observed the records are in compliance. During the visit, LPA observed the facility has a supply of Personal Protective Equipment (PPE) and Mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. A working land line phone was operational. The last fire drill was conducted on May 5, 2026. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 9/1/2025 – 9/1/2026. A review of five residents (R1-R5) service files and two staff (S1-S2) personnel files revealed to be complete. The facility has the current administrator's certification on file for Theresa Kholoma - Expiration 4/28/2027. No deficiencies during this inspection visit. An exit interview was conducted with House Manager Rudy Ignacio, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 29, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Glenn Espiritu and the purpose of the inspection was discussed. Licensee Rudy Ignacio was contacted by phone and arrived at approximately 1:45 p.m. During the inspection, LPA and Staff Susan Curay conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following: This is a one-story home with six resident bedrooms, three bathrooms, living room, dining room, kitchen, and detached two-car garage. In three unlocked kitchen drawers, LPA observed staffs’ personal belongings including toiletries and staffs’ own personal medication and supplements; a Deficiency was cited on today’s date. In the garage, LPA observed a corner of the garage to be covered and made into a makeshift bedroom containing a bed, made with linen, blankets, and pillows, and staff's personal belongings, including clothing and shoes; a Deficiency was cited on today’s date. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. The backyard has a shaded sitting area. LPA observed residents having lunch and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 118.0 degrees Fahrenheit. LPA observed the facility has 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 service tag dated August 18, 2025. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. (Cont. LIC809-C) Toxic chemicals, cleaning solutions, and disinfectants were observed to be accessible in the kitchen to residents who are at safety risk if allowed access; a Deficiency was cited on today’s. Medication was observed to be centrally stored and locked, however, medication is being pre-poured into a plastic weekly medication organizer for two of five residents; a Deficiency was cited on this date. LPA reviewed three resident files and three staff files. LPA interviewed three residents and three staff. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Sep 24, 2025

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Jun 21, 2024

The state marks this report as 12 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff locked resident in their room. Staff administered medication that was not prescribed to resident.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the two allegations listed above. LPA was greeted and granted entry by facility staff after stating the reason for the visit. House Manager Rudy Ignacio was notified of the visit via telephone and arrived later to assist with the visit. An initial complaint investigation visit was conducted on August 8, 2023. A tour of the facility's physical plant was conducted along with a review of resident records and an interview with the administrator. A follow-up visit was later held on August 25, 2023 with 4 staff interviews completed. Additional witness interviews were also conducted via telephone during the investigation. A total of five resident interviews were finally attempted or conducted during the present visit. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff locked resident in their room, the following has been concluded: Based on observation made in the physical plant, records reviewed and interviews conducted, LPA could not sufficiently evidence that any of the facility's door were equipped with a lock or a locking latch at the time of the allegations. Staff, witnesses and residents interviewed denied any knowledge of a resident ever being locked in their room. The allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did occur. Regarding the allegation that Staff administered medication that was not prescribed to resident, the following has been concluded: Based on evidence gathered, medication reviewed, records reviewed and interviews conducted, it could not be sufficiently evidenced that medication belonging to another resident was at any point administered to another resident for the purpose of managing their behavior. All medication observed during the three site visits were prescribed to a resident currently admitted and verified as such. However, in the presence of a photograph of medication on which the label had been marked off with a marker, the Department could not sufficiently ascertain that the allegation did not occur either. As a result, the allegation is therefore found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did occur. A Technical Assistance Advisory Note is however issued to remind licensee that per Title 22 Regulations "No persons other than the dispensing pharmacist shall alter a prescription label". An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Oct 25, 2023 · control 22-AS-20230804111101