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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 06:28:59 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cezar C. Tolentino, caregiverTIME COMPLETED:
06:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Emily Peraldi and Kelly Dulek arrived to this location today for the purpose of conducting a Case Management – Deficiencies visit. At 10:15 a.m. LPAs 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.- 1:45 p.m. LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards.



Between 10:22 a.m.- 10:30 a.m., LPAs toured the kitchen and storage areas. The facility does not have a week of non-perishable food and does not have two days supplies of perishable food. LPAs observed the refrigerators in the garage being used as storage. LPAs called Administrator and asked about the food at the facility. Administrator stated that the groceries are done once a week and that food will be delivered on 11/08/2021. At 12:35 p.m. an individual dropped off groceries at the facility.

At 10:21 a.m. LPAs observed knives/sharp’s drawer and cleaning supplies unlocked and accessible to residents. Upon observation, staff locked up the drawers and cabinets making the knives and cleaning supplies inaccessible. At 10:26 a.m. the garage door was open and left accessible to residents. The garage has cleaning supplies, tools and other items that could constitute a danger to the residents. At 10:36 a.m. LPAs observed two first aid kits in the closet of resident room four (4).

At 10:36 a.m., LPAs were in the garage when an Individual #1 (I1) opens the garage door and enters the facility. I1 quickly left and at 12:30 p.m. arrived at the facility again. I1 is excluded from being present in a licensed facility. At 1:40 p.m. I1 left the facility.

Continued on LIC 809-C.
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)
Page: 1 of 8
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: 11/08/2021
NARRATIVE
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Continued from LIC 809.

Between 10:38 a.m. -10:56 a.m. LPAs interviewed three (3) residents out of six (6). At 10:38 a.m. LPAs observed room one (1) having urine on the floor and on Resident #1’s (R1) bed. LPAs also observed room one (1) having the scent of urine. LPAs observed feces on R1’s hands.

At 10:56 a.m. LPAs observed over the counter medication in resident room two (2). At 1:24 p.m., Staff #1 (S1) left the medication closet open and accessible to residents.

At 12:17 p.m. LPAs observed the back glass door missing a screen. At 12:36 p.m. LPA Dulek observed one (1) out of two (2) side gates locked. The second side gate has the door locked engaged but since the gate frame is uneven, the door is unable to be locked. Resident rooms one (1), and four (4) have doors that are difficult to open. At 12:30 p.m. LPA Peraldi conducted record reviews of the facility. Per record reviews, resident room one (1) is cleared for ambulatory only and resident room three (3) is cleared for bedridden. The other rooms are cleared for non-ambulatory. R1 is bedridden and is in resident room one (1). Again, room one (1) is cleared for ambulatory only.

At 12:30 p.m. LPA Peraldi conducted resident record reviews. Per record reviews, the facility has at least one (1) dementia resident. The facility only has resident records for five (5) out of six (6) residents.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $1,000.00 is also assessed.

Exit interview conducted. A copy of the report was issued via email. Civil penalties and related appeal rights issued via email.
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
LIC809 (FAS) - (06/04)
Page: 2 of 8
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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited

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87202(a)(1) Fire Clearance
Fire Clearance. Prior to accepting or retaining any of the following types of persons, the…licensee shall...obtain an appropriate fire clearance…nonambulatory persons. This requirement is not met as evidenced by:
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Based on record review and observation, the licensee did not ensure the facility had a nonambulatory fire clearance for Room #1 before a nonambulatory resident resided in it, which posed an immediate health and safety risk to residents in care.
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Type A
11/09/2021
Section Cited

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87705(f)Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication...This requirement is not met as evidenced by:
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Based on observation, the licensee did not ensure tools, sharp items, and medication were inaccessible to residents with dementia when the garage and medication storage was left open and the knife cabinet unlocked and accessible, which posed 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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited

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87411(a)
Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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Based on interview and observation, the licensee did not ensure the facility had sufficient staff to meet all residents’ needs (R1), which posed an immediate health and safety risk to residents in care.
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Type A
11/09/2021
Section Cited

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HSC 1569.625(b)(1)
Staff Training...A staff member shall complete 20 hours…before working independently with residents. This requirement is not met as evidenced by:
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Based on interview and record review, the licensee did not ensure staff received adequate training as required before providing care to residents in 1 out of 2 staff (S1), which posed 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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 4 of 8
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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2021
Section Cited

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87555(b)(26)
General Food Service Requirements. Supplies of…perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
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Based on observation, the licensee did not ensure the facility had at least two days of perishable food, which posed a potential health and safety risk to residents in care.
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Type B
11/22/2021
Section Cited

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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
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Based on observation, the licensee did not ensure that doors to the resident rooms are in good repair and that back glass door is missing a screen which posed 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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 5 of 8
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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited

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87113 Posting of License. The license shall be posted in a prominent location in the licensed facility accessible to public view. This requirement is not met as evidenced by:
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Based on observation, the licensee did not ensure the facility’s license was posted, which posed a potential health and safety risk to residents in care.
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Type B
11/22/2021
Section Cited

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87705(h)Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by:
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Based on observation, the west outdoor gate is not self-closing and self-latching which posed 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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 6 of 8
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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2021
Section Cited

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87356(q)(2) Criminal Record Exemption. An exclusion order based solely upon a denied exemption shall remain in effect and the individual shall not be employed in or present in a licensed facility...unless either a petition or an exemption is granted.This requirement is not met as evidenced by:
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Based on interview and observation, the licensee did not ensure an excluded individual (identifier) was not present at the facility on multiple occasions, which posed an immediate health and safety risk to residents in care.
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Type A
11/09/2021
Section Cited

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87405 Administrator qualifications (d) The Administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
This requirement is not met at evidenced by:
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Based on interview, the Administrator was unaware of the staff schedule for the facility and the Administrator did not understand uncleared individuals could not be present in the facility, which poses an immediate health and safety hazard to residents in care.
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Training must be completed by 11/22/2021.
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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 7 of 8
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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2021
Section Cited

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87625Managed Incontinence (b) ...the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:

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Based on observation and interview, 1 resident (R1) out of 6 residents, was observed to be left in their soiled bed, with soiled clothing, bedding, and pads, as well as feces on R1’s hands, and LPAs observed R1’s room smelled of urine, which poses an immediate health risk to residents in care.
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Training must be completed by 11/22/2021.
Type A
11/12/2021
Section Cited

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87506 (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
This requirement is not met as evidenced by:
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Based on observation and interview, the licensee did not comply with the section cited above, as there is no resident record for 1 out of 6 residents (Resident #2-R2), 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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
Page: 8 of 8