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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600819
Report Date: 10/30/2023
Date Signed: 10/30/2023 01:31:45 PM


Document Has Been Signed on 10/30/2023 01:31 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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: 5DATE:
10/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Leonora ManejaTIME COMPLETED:
01:40 PM
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On 10/30/2023 at 12:05 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Leonora Maneja, Administrator.

On 10/28/2023 LPA received a voicemail about a resident (R1) who passed away. On 10/30/2023 LPA received the death report for the same resident. In the report it lists the cause of death "Natural Death" and states that R1 condition prior to or contributing to Death was "vomit and pass out".

LPA interviewed S1 and collected the following documents: physicians report 2022, physicians report 2023, Needs and services plan, and the MARS.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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