195850162-8-25-2021-29-AS-SURA-C68S6T-20210825133629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850162
Report Date: 08/25/2021
Date Signed: 08/25/2021 01:36:57 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: 2	DATE:	08/25/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Fanny Moran		TIME COMPLETED:	01:45 PM

NARRATIVE

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At 10:00am, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case management deficiencies Plan of Correction visit at the facility today due to deficiencies observed during the annual random inspection done on 08/11/2021.

At 10:15 a.m., the LPA observed that the gate found out of compliance is unlocked, however the gate’s single self-latch continues to be broken, which poses a potential health and safety risk to residents.

At 10:30 a.m., the LPA identified a new staff #5 (S5), who stated that the date of starting to work at facility was Monday, August 23rd, 2021. The LPA conducted LIS personnel check to check for the staff associated to this facility. Staff present at facility today was not found to be associated with this facility. Additionally, staff #1 (S1) was found to not be associated with facility as of 08/11/2021. S5 personnel file was present, however, documents were missing S5’s signature as acknowledgement of the conditions for employment. This requirement is not met as evidenced, as two out of two staff present on this day were not associated with facility, and which poses a potential health and safety risk to residents.

At 11:30 am, the LPA requested the resident’s #5 (R5) missing file per the 08/11/2021 annual random visit. A stack of documents was presented by staff; however, the resident’s file was incomplete as signatures were missing from most documents. A physician’s incomplete report was included in the documents as no evidence of a TB test was included in the LIC 602A. The LIC 603 Pre-placement Appraisal was missing from the file. R5 was not present at time of today’s visit. Administrator stated that R5 decided not to stay at facility.

Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/25/2021 Section Cited	1 2 3 4 5 6 7	87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance…
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above, as one individual (S5) has been working at the facility without a criminal record transfer as 08/23/2021.	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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC809 (FAS) - (06/04)

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