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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850162
Report Date: 12/02/2021
Date Signed: 12/02/2021 05:50:55 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: 4DATE:
12/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Cezar Tolentino, DesigneeTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Salia Walker and Elsie Campos conducted an unannounced Case Management- Deficiencies inspection at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20211123163312. The LPA met with Designee Cezar Tolentino at 1:37 p.m., and explained the reason for the visit.

At 1:41 p.m., it was communicated to the LPAs by staff that Resident #1 (R1) passed away at the facility on or approximately November 3, 2021. It was also communicated by staff, that Resident #2 (R2) was Hospitalized for Renal failure/ abdominal pain. An incident report was not submitted to the Department, notifying the Department of the incidents. The LPA advised the administrator via telephone, written report shall be submitted to the licensing agency within seven days of any incident which threatens the welfare, safety or health of any resident. The administrator acknowledged, and stated that the facility will be notifying all incidents pertaining to residents in the future to CCLD.

At 1:48 p.m., the LPAs observed razors accessible to residents in care in bathroom C located between bedroom #2 and #3. The staff immediately locked and secured the razors at the time of observation. The Administrator was notified via telephone of accessible razor observed.

At 1:53 p.m., the LPAs observed that two (2) out of two (2) facility side gates contained dead-bolt mechanisms instead of single-latch. The LPAs advised staff this is a fire clearance violation. The LPAs informed the administrator via telephone, and they stated that they would remove the mechanism of the lock to ensure that it was single-latch only. At 4:45 p.m., the LPAs observed S1 removed the dead-bolt mechanism during the visit.


Continued on LIC809C..
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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 5
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: 12/02/2021
NARRATIVE
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At 1:59 p.m., during the physical plant tour the LPAs observed the facility kitchen refrigerator contained expired condiments. S1 removed the expired condiments and discarded them into the trash bin.

At 2:04 p.m., during the physical plant tour the LPAs observed the facility garage unlocked containing accessible cleaning supplies, laundry detergent, chemicals. The LPAs advised the Administrator via telephone of accessible items. The Administrator acknowledged and stated staff would be retrained.

At 3:28 p.m., the LPAs advised the administrator no staff files were found at the facility for S1 or S2. The administrator stated that the staff files and Facility staff roster are currently in her possession due to file being requested for an appointment with an investigator. The LPAs advised the administrator, that files shall be kept in the facility readily available to Licensing Agency at all times. The Administrator acknowledge understanding.

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: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as two (2) out of two (2) facility gates contained dead-bolt mechanisms instead of single-latch only, which poses an immediate health and safety risk to residents in care.
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Type A
12/03/2021
Section Cited

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87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as... cleaning supplies ...
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as cleaning supplies, razors, and ointment were accessible to residents with dementia, 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: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2021
Section Cited

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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety or health of any resident.
This requirement is not met as evidenced by:
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Based on interviews, the licensee did not comply with the section cited above, as an incident report was not submitted for R1's death nor for R2's Hospitalization, which poses a potential health and safety risk to residents in care.
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Type B
12/07/2021
Section Cited

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87412(g) Personnel Records (g)All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the section cited above, as two (2) out of (2) staff files were not available to the licensing agency, 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2021
Section Cited

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87555(b)(8) General Food Service Requirements(b)The following food service requirements shall apply:(8)All food shall be of good quality.. Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as expired food was observed in the facility kitchen refrigerator, which poses a potential health, and safety risk to persons 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: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5