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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850162
Report Date: 11/08/2021
Date Signed: 11/08/2021 06:26:27 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: 6DATE:
11/08/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cezar C. Tolentino, caregiverTIME COMPLETED:
06:30 PM
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Licensing Program Analysts (LPAs) Emily Peraldi and Kelly Dulek arrived to this location today for the purpose of conducting a Plan Of Correction / Case Management (POC) visit to follow up on the Plan of Correction citation issued during the case management visit conducted on 11/04/2021 by LPA Emily Peraldi.
At 10:15 a.m. LPA met with caregiver Cezar C. Tolentino and explained the reason for visit. Administrator was unavailable to meet with the LPAs and authorized Cezar to sign the report.

Between 10:21 a.m.- 12:45 p.m. LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

At 11:19 a.m. LPA Peraldi had a discussion with Administrator via telephone call regarding the submission of plan of corrections (POCs) from visits on 11/04/2021. On 11/04/2021, the facility was cited for not transferring the criminal record clearance of Staff #1 (S1), Staff #2 (S2) and newly hired Administrator. The Proof of Correction was due on 11/05/2021. Administrator emailed LPA Peraldi incomplete POC on 11/05/2021. On 11/08/2021, Administrator emailed LPA Peraldi the correct POC.

At 2:45 p.m. LPA Peraldi returned documents that were removed during 11/04/2021 visit.

Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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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