157206689-7-9-2024-24-AS-MMEA-D6ZRY7-20240709132552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157206689
Report Date: 07/09/2024
Date Signed: 07/09/2024 01:26:59 PM

Document Has Been Signed on 07/09/2024 01:26 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, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	A COMFORT CARE HOME		FACILITY NUMBER:	157206689
ADMINISTRATOR:	SCHISSLER, EVANGELINE T.		FACILITY TYPE:	740
ADDRESS:	12409 ANDES AVE		TELEPHONE:	(323) 237-4781
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93312
CAPACITY:	6	CENSUS: 6	DATE:	07/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:26 AM
MET WITH:	Evangeline Schissler		TIME COMPLETED:	01:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/9/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA arrived, introduced self, stated purpose of visit, and allowed entrance by caregiver. Evangeline Schissler arrived a few minutes later to conduct visit with LPA. Upon entry, LPA did not observe any required postings available. LPA observed facility to be clean, odor free, and temperature to be 73 degrees. Facility observed to be equipped with auditory alarms on all exit doors however not in the "on" position. Resident rooms toured. All common areas observed to have adequate seating available for residents. Bathrooms observed to have grab bars, shower chairs, and non-skid mats available. Fixtures in the bathroom observed to be functional. Water temperature measured at 113 degrees F. Kitchen toured, facility has a 7-day supply of non-perishable food, however does not have a 2 day supply of perishable food available. LPA observed food in refrigerator to be stored and not dated. LPA also observed canned food in pantry beyond expiration date. Knives and scissors observed to be in drawer but unlocked and accessible to residents, LPA also observed knives in dish rack. Medications requiring refrigeration observed to be in the refrigerator and accessible to residents. LPA observed a kitchen drawer with AM medications pre-dispensed and waiting to be administered, unlocked and accessible to residents. Medications in hallway cabinet observed to be unlocked. All medications observed to have original labels. LPA observed smoke detectors and carbon monoxide detector to be operational during facility inspection.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda Medina	TELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: A COMFORT CARE HOME	FACILITY NUMBER: 157206689
	VISIT DATE: 07/09/2024

NARRATIVE

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Outside of facility toured. Pool is surrounded with a 5 foot wrought iron fence, observed to be locked and secured and inaccessible to residents. No hazards observed.

LPA will return to conduct staff and resident file reviews.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiencies are being cited on the attached 9099-D.

Exit interview conducted. Appeal rights provided. A copy of the sign report provided for facility records.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda Medina	TELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/09/2024 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: A COMFORT CARE HOME	FACILITY NUMBER: 157206689
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: LPA observed medication which was pre-dispensed in an unlocked kitchen drawer. LPA observed medication requiring refrigeration to be in refrigerator and accessible to residents. Medication cabinet in hallway was unlocked.
	Deficient Practice Statement
1 2 3 4	Based on bservation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	Licensee will keep pre-dispensed medication in locked medication cabinet in hallway. All medication requiring refrigeration will be contained in locked box in refrigerator. Medication cabinet in hallway to remain locked at all times.

Type A

Section Cited

CCR

87705(f)(1)

The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: LPA observed a knives and scissors in an unlocked kitchen drawer. LPA also observed a knife in the dish rack in kitchen sink.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	All knives and sharps will remain in locked drawer and inaccessible to residents. Knives were locked and secured at time of visit. DEFICIENCY CLEARED DURING INSPECTION

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: Melinda Hoffmann	TELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda Medina	TELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/09/2024 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: A COMFORT CARE HOME	FACILITY NUMBER: 157206689
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(26)

Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: LPA did not observe a 2-day supply of perishable food available during inspection.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	Licensee will submit grocery receipt for 2-day supply of perishable food to Fresno Regional Office no later than POC due date

Type B

Section Cited

CCR

87755(9)

Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: LPA observed left over food stored in refrigerator without dates. LPA also observed canned food in the pantry beyond the expiration date.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Licensee to ensure that all food in refrigerator is properly stored and dated. All pantry food shall be checked and expired food shall be removed from facility.

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: Melinda Hoffmann	TELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda Medina	TELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/09/2024 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: A COMFORT CARE HOME	FACILITY NUMBER: 157206689
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(j)

Care of Persons with Dementia: The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: LPA observed auditory alarms on all exit doors, however, were not placed in the "on" position
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 4] out of 4 exit doors the auditory alarm was not in "on" position which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2024
	Plan of Correction
1 2 3 4	Licensee to ensure that all auditory alarms remain in the "on" position. All auditory alarms were placed in the "on" position during inspection. DEFICIENCY CLEARED AT TIME OF INSPECTION.

Type B

Section Cited

CCR

87468(C)

Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. This requirement is not met as evidenced by: LPA did not observe any postings upon entry to facility
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2024
	Plan of Correction
1 2 3 4	Licensee to ensure all required postings are posted in facility near entry point.

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: Melinda Hoffmann	TELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda Medina	TELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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