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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600819
Report Date: 12/06/2022
Date Signed: 12/06/2022 01:19:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/31/2022 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20221031085430
FACILITY NAME:COMFORT CARE HOME, LLCFACILITY NUMBER:
075600819
ADMINISTRATOR:REY & MARY JANE VELASQUEZFACILITY TYPE:
740
ADDRESS:870 SAN SIMEON DRIVETELEPHONE:
(925) 680-4682
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 6DATE:
12/06/2022
UNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Leonora Maneja, AdministratorTIME COMPLETED:
01:29 PM
ALLEGATION(S):
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Staff spoke inappropriately to resident while in care
Staff did not adequately supervise resident in care resulting in resident’s head being covered by a blanket
Staff are not ensuring that documentation regarding residents in care are maintained accurately
INVESTIGATION FINDINGS:
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On 12/06/2022 starting at 11:40 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to to deliver findings on the above allegation. LPA met with Leonora Maneja, Administrator and explained the purpose of the visit.

Based on LPAs interviews, 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, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20221031085430
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMFORT CARE HOME, LLC
FACILITY NUMBER: 075600819
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2022
Section Cited
CCR
87413(a)(2)
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In each facility: Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.

This requirement is not met as evidenced by:
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The facility will conduct an all staff training about a proper communication to the residents.
The facility will submit a log of attendence for the training to CCLD by POC date.
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Based on interviews & records reviews, Licensee did not comply with the regulation above, a staff member commenting on a reisdents physical appearance in a neagtive manner
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Type B
12/20/2022
Section Cited
HSC
1569.269(a)(10)
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Residents of residential care facilities for the elderly shall have all of the following rights:
To be free from neglect...or abuse.

This requirement is not met as evidenced by:
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The Facility will conduct a staff training about Care and supervison of the residents. The facility will submit a log of attendence for the training to CCLD by POC date.
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Based on interviews & observations, Licensee did not comply with the regulation above, by allowing a resident to sit for a period of time with a banket covering their head
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20221031085430
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMFORT CARE HOME, LLC
FACILITY NUMBER: 075600819
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2022
Section Cited
CCR
87506(a)
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The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff

This requirement is not met as evidenced by:
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The facility will review the regulation and submit a letter of self certification to CCLD by POC date.
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Based on interviews & records reviews, Licensee did not comply with the regulation above,by having the records taken home for updating.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3