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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850162
Report Date: 02/25/2022
Date Signed: 02/25/2022 04:01:58 PM


Document Has Been Signed on 02/25/2022 04:01 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:COMFORT ELDERLY CAREFACILITY NUMBER:
195850162
ADMINISTRATOR:MAKHTESYAN, DIANAFACILITY TYPE:
740
ADDRESS:22806 CALIFA STREETTELEPHONE:
(818) 602-1622
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 2DATE:
02/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rogelia Macapia and Naira ParoyanTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced at the facility to follow up on a possible facility closure. The LPA was allowed entry into this location by Rogelia Macapia. At the time of the visit, there were two residents and one staff member. The LPA contacted Naira Paroyan via telephone and informed them of the reason for the visit.

On February 24, 2022, Ms. Paroyan informed the Department that as of March 1, 2022, the license for this location would be placed 'on hold' due to insufficient staffing. As a result, residents at this location would be relocated. Ms. Paroyan did not detail the locations as to where the residents would be moved.

At 2:18 p.m., the LPA spoke with Ms. Paroyan, whom confirmed that the facility would temporarily close due to lack of staffing, as their previous staff no longer worked at this facility. The LPA explained that the facility would still held to licensing standards, even if there were no residents residing in this location. Ms. Paroyan claimed that they did not want to surrender the license at this time.

Ms. Paroyan confirmed that they informed the residents' responsible parties of the relocation. At this time, one out of four residents (R1) was relocated to a licensed facility (Victoria's Dignity Care - 197610144), and one out of four residents (R2) is currently in the hospital. Ms. Paroyan claimed that R2 would not return, as they could not care for R2's needs. The LPA explained to Ms. Paroyan that when R2 was cleared for discharge, they were still a resident of this location and would need to be discharged back to this facility. Ms. Paroyan agreed and stated that they would allow R2 to come back and would assist with relocation.

During today's visit, a file review was conducted at 1:45 p.m., the LPA interviewed staff at 1:40 p.m. and 2:18 p.m., and interviewed a resident at 1:37 p.m. Per the file review, staff Rogelia Macapia is not associated to this location. Ms. Paroyan claimed that today was their first day working at this location. Ms. Macapia was unable to share any details regarding residents currently residing at this location.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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: 02/25/2022
NARRATIVE
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CONT. FROM 809-C

In addition, the following was observed: two out of four residents (R2, R3) failed to have a signed personal rights form or completed appraisal on file, and two out of four residents (R1, R4) needed an updated appraisal. There was no file for S1 at the facility.

A physical plant tour was conducted at 3:40 p.m. At 3:42 p.m., accessible medications were observed in the refrigerator. The medications required refrigeration, however they were not stored in a separate lockbox. No other immediate health and safety concerns observed in this location at this time.

Per California Code of Regulations (CCR), Title 22, see LIC 809-D for deficiencies cited. Exit interview conducted. Civil penalties assessed. A copy of the report was issued via email, along with appeal rights.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/25/2022 04:01 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2022
Section Cited

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87355(e)(1) Criminal Record Clearance. (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required...
This requirement is not met as evidenced by:
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Based on record review and interview, the licensee did not comply with the section cited above in one out of one staff (S1), as they were not associated to work at this facility, which poses an immediate health and safety risk to residents in care.
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Civil penalties assessed in the amount of $100.
Type B
03/04/2022
Section Cited

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87463(c) Reappraisals. The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff... there is significant change in the resident’s condition, or once every 12 months...
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply in the section cited above for four out of four residents (R1, R2, R3, R4), which poses a potential health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/25/2022 04:01 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited

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87468(b)(1)(A) Personal Rights. At the time the admission agreement is signed, a resident ... shall be personally advised of and given a copy of: (1) The personal rights of residents... (A) ... the signed copy shall be included in the resident's record.
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply in the section cited above for two out of four residents (R2, R3), which poses a potential personal rights risk to residents in care.
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Type B
03/04/2022
Section Cited

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87412(a) Personnel Records. (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply in the section cited above for one out of one staff members (S1), which poses a potential health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 02/25/2022 04:01 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: COMFORT ELDERLY CARE
FACILITY NUMBER: 195850162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2022
Section Cited

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87465(h)(2) Incidental Medical and Dental Care. 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 was not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as accessible medications were observed in the refrigerator, which poses an immediate health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5