<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850162
Report Date: 08/13/2021
Date Signed: 08/13/2021 02:52:01 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 CAREFACILITY NUMBER:
195850162
ADMINISTRATOR:MAKHTESYAN, DIANAFACILITY TYPE:
740
ADDRESS:22806 CALIFA STREETTELEPHONE:
(818) 602-1622
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 5DATE:
08/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Dawn SmithTIME COMPLETED:
03:15 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 08/13/2021 at 11:30 am Licensing Program Analyst (LPA) Sandra Urena arrived at the facility, and explained the reason for the visit. LPA conducted a subsequent Case Management- Plan of Correction Visit (POC) visit.

08/11/2021 LPA Urena conducted an annual random inspection, and found that 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.

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.

On 08/13/2021, at 11:45am LPA started by touring the outdoor area to check on the POC due 08/13/2021 for the locked gate on the west side of the property. Before exiting through the the sliding glass door, (S2) stated that per the supervisor of S2, the gate had been unlocked. As I proceeded again to continue to exit the facility, S2 asked, "did you hear me?", LPA Urena replied, "yes" and continue to go out to the outdoor area to check on the gate. The west side gate is still locked, and self latching lock is missing.

At 12:15 pm the LPA requested the missing files for three staff and one additional staff observed on today's visit. Files were not available at facility. The LPA also requested to see the missing file for R5. FIle was not available for review at facility. S2 stated that no one has been at facility.





SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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 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: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2021
Section Cited

1
2
3
4
5
6
7
(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and
shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council.
Type B
08/11/2021
Section Cited

1
2
3
4
5
6
7
(b) The following food service requirements shall apply:
(5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents.
This requirement is not met at evidence by: Based on observation, LPA observed S2 served pinto beans, corn bread and water to residents (1, 2)for dinner. Licensee did not comply with General Food Service Requirements-Food Variety.
8
9
10
11
12
13
14
This requirement is not met at evidence by: Based on observation, LPA observed S2 served pinto beans, corn bread and water to residents (1, 2)for dinner. Licensee did not comply with General Food Service Requirements-Food Variety.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
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: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021
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
VISIT DATE: 08/13/2021
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
26
27
28
29
30
31
32
At 12:20 pm the LPA noticed S4 in the kitchen area and inquired about the meal served for lunch. S4 stated that lunch was composed of egg sandwich, crackers, and juice. LPA asked, "what type of juice?" S4 stated, "orange juice", and proceeded to open the refrigerator and showed LPA a pitcher with a brown liquid in it. When asked again by LPA what kind of juice is that?, S4 stated, I don't know. At this time, S2 enterd the kitchen area and stated once again that residents received orange juice for lunch. LPA asked about the brown liquid in the pitcher, then S2 stated, I guess its chocolate milk.

On 08/11/2021 at approximately 4:00pm, LPA Urena observed staff serve for dinner to resident #1 (R1), and resident #2 (R2) a bowl of pinto beans, two squares of corn bread and half glass of water. LPA Urena asked Staff # #2 (S2) about the serving of vegetables, and fruit ,and offering a choice of drink to residents? S2 stated that residents had already received vegetables and fruit at lunch. S2 stated that residents usually get an orange flavored drink, but the facility had run out of it.

During today’s visit LPA issued Civil Penalties for the citations issued on 08/11/2021 annual random visit. Additionally, LPA Urena issued today additional citations.

Exit interview conducted. Citations were issued. Copy of the report was emailed to administrator.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2021
Section Cited

1
2
3
4
5
6
7
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.

8
9
10
11
12
13
14
Based on interviews, the staff made false claims to CCL staff regarding the status of the side outdoor gate being unlocked, and drink served to residents for lunch, which poses an immediate health and safety risk to residents in care.

8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4