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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850162
Report Date: 06/29/2022
Date Signed: 06/29/2022 11:02:03 AM


Document Has Been Signed on 06/29/2022 11:02 AM - 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: 0DATE:
06/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Diana MakhtesyanTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a Case Management – Deficiencies visit due to deficiencies observed during the investigation of complaint control # 29-AS-20211123163312.

During the initial visit conducted on 2/25/2022, the LPA was let into the property by staff Rogelia Macapia (S1). During that visit, S1 first claimed that they had been working at the facility two weeks prior to the LPA's visit, but later in the visit, S1 claimed it was their first day working at the location. S1 confirmed that they were also living in the facility. Former Administrator Naira Paroyan also made claims that it was S1's first day at the facility. However, after conducting an in depth file review, it was confirmed that S1 was working at the facility at least since January 2022, as S1 was interviewed by Investigator Dennis Douglas on 1/28/2022, whom was conducting interviews during the investigation of complaint control # 29-AS-20211112142407. At that time, S1 had claimed that it was their ‘first day’ working at the facility.

The facility did not have any staffing records on file. At this time, additional civil penalties will be assessed due to lack of criminal record clearance, as S1 was never associated to the facility. The licensee was initially cited for a penalty of $100, as S1 claimed to had only worked one day as of 2/25/2022.

Licensee has been cited for failure to ensure that persons worked at this facility with appropriate criminal record clearance on the following dates 2/25/2022, 11/8/2021, 11/4/2021, 8/25/2021. The licensee will be assessed an additional fourteen (14 days) as S1 initially noted that they had been in the facility for two weeks.

Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were provided. Civil penalties issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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 2


Document Has Been Signed on 06/29/2022 11:02 AM - 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: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2022
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: (2)
Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement is not met as evidenced by:
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This requirement is not met as evidenced by: 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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Type A
06/30/2022
Section Cited

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87207 False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
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 provided false statements to CCL employees, 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: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
LIC809 (FAS) - (06/04)
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