195850162-8-11-2021-29-AS-SURA-C5T3M4-20210811182144

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850162
Report Date: 08/11/2021
Date Signed: 08/11/2021 06:22:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COMFORT ELDERLY CARE		FACILITY NUMBER:	195850162
ADMINISTRATOR:	MAKHTESYAN, DIANA		FACILITY TYPE:	740
ADDRESS:	22806 CALIFA STREET		TELEPHONE:	(818) 602-1622
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	08/11/2021
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Dawn Smith		TIME COMPLETED:	04:30 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 08/11/2021 at 1:30 pm, Licensing Program Analyst (LPA) Sandra Urena arrived at the facility, introduced herself and explained the reason for the visit. LPA conducted an unannounced required annual inspection visit. Administrator was not available at facility. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. INFECTION CONTROL: Upon entry, the facility has a sign in book and sanitizing gel. Infection Control signs were visible at entrance. However, caregivers did not ask the LPA to use sanitizer, wash hands nor took temperature at arrival. No infection control questions were asked to the LPA prior to entering facility. Facility Records: At 1:45 pm, the LPA requested staff and residents’ records Personnel records were not available at facility. LPA contacted Administrator via phone, the call went to voicemail. LPA Urena left voicemail to administrator requesting staff files. Additionally, the LPA texted administrator requesting files. The administrator texted back stating that she could not bring the files due to other matters. Resident Records: The facility houses five residents, however on today’s visit only four files were available for review at the facility. Caregiver stated that a new resident was admitted this week, and the facility did not have the file for this resident. The LPA asked caregiver for the new resident’s full name, and caregiver could only provide the first name.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT ELDERLY CARE	FACILITY NUMBER: 195850162
	VISIT DATE: 08/11/2021

NARRATIVE

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Outdoor Space: At 3:15 pm, LPA observed the Outdoor space. A shaded patio is available for residents to
visit with family members. The outdoor area has two gates, one on each side of the facility. The gate on the east side is unlocked and has a self-latching closure. The gate on the west side is locked with key, and does not have self-latching closure.

Bedrooms: At 3:30 pm, LPA observed the Residents’ bedrooms. Bedrooms were furnished appropriately
with clean linens, appropriate furnishings and sufficient lighting.

Bathrooms: At 3:45 pm, LPA observed the Residents’ restroom. Restrooms was clean, shower area was
in clean condition with grab bars and non-skidsident mat available.
Hand washing sign was displayed. Paper towels were not available for drying hands

Kitchen: At 4:00p pm, LPA observed the kitchen/dining area. Knives are stored in a locked cabinet drawer.
Kitchen appliances were in operable condition. Freezer and refrigerator are stocked with a variety of foods. However, on today’s visit, dinner consisted of a bowl of cooked pinto beans and two squares of corn bread and one glass of water. Caregiver stated that they usually offer an orange flavor beverage and tea, but they had run out. Caregiver stated that residents received vegetables and fruits during today’s meals earlier in the day. Emergency food supply consists of canned goods, Vienna sausages (10), Tuna (7), Kidney beans (10), Pork Beans, and one five-gallon water.

LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain
additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Deficiencies were cited at this time. Administrator was not available to sign reports, staff present declined to take part of the exit interview and to sign report. A copy of report was Issued via email to Licensee/Administrator.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT ELDERLY CARE	FACILITY NUMBER: 195850162
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(1)

This requirement is not met as evidenced by: LPA noted that the west side gate is locked with key and has no self-closing latches
	Deficient Practice Statement
1 2 3 4	(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.
	POC Due Date: 08/13/2021
	Plan of Correction
1 2 3 4	2. Licensee to immediately unlock west side gate. Licensee to install a self-latch closure. If licensee requests a locked gate, licensee to submit an exception to licensing. Licensee must obtain fire clearance approval before a lock can be put on the gate.

Type A

Section Cited

CCR

8750(a)

This requirement is not met as evidenced by: Licensee didnot comply with section cited above as one out five residents files are not present at the facility, which poses a potential health and safety risk to residents.
	Deficient Practice Statement
1 2 3 4	87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.
	POC Due Date: 08/13/2021
	Plan of Correction
1 2 3 4	The administrator must submit proof that facility has R1 records avalable at the 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT ELDERLY CARE	FACILITY NUMBER: 195850162
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(g)

This requirement is not met as evidenced by: Licensee did not comply with above citation as three out othree staff files were not available at facility upon request for review, which poses a potential health and safety risk to residents.
	Deficient Practice Statement
1 2 3 4	All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
	POC Due Date: 08/13/2021
	Plan of Correction
1 2 3 4	Administrator to submit proof by 8/13/2021of staff files available at facility ready for review upon inspection.

Type A

Section Cited

CCR

87411(a)

This requirement is not met as evidenced by: Facility did not comply with above citation as three out of three staff were not associated with facility, and which poses a potential health and safety risk to residents.
	Deficient Practice Statement
1 2 3 4	87411(a)- Personnel Requirements Facility personnel shall at all times be sufficient in numbers to provide the services necessary to meet residents needs.
	POC Due Date: 08/13/2021
	Plan of Correction
1 2 3 4	Administrator must submit proper documentation to Regional Office in order to associate staff with the facility by 8/13/2021.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC809 (FAS) - (06/04)

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