195850162-12-10-2021-29-AS-SWAR-C9L3FJ-20211210171249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850162
Report Date: 12/10/2021
Date Signed: 12/10/2021 05:13:22 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: 4	DATE:	12/10/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Cezar Tolentino, Designee		TIME COMPLETED:	05:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Plan of Correction (POC) visit to follow up regarding the plan of corrections that were due for submission to CCL by 12/3/21; 12/6/21; and 12/7/21. The LPA met with Designee Cezar Tolentino at 1:40 p.m., and explained the reason for the visit.

On 12/2/2021, LPAs Walker and Campos conducted an unannounced Case Management- Deficiencies inspection where the following deficiencies were cited, and a civil penalty was issued.

During 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 LPAs advised the administrator via telephone, written reports 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. The plan of correction agreed upon for citation under section 87211(a)(1)(D) was to, ‘Submit an incident report pertaining to R1's death and R2's Hospitalization to CCL by 12/7/2021.’

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. 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. The Administrator was notified via telephone of accessible razor observed. The plan of correction agreed upon for citation section 87705(f)(2) was to, ‘Submit staff training log of section 87705(f)(2) to CCL by 12/3/2021.’

Continue on LIC809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

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
	VISIT DATE: 12/10/2021

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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. The plan of correction agreed upon for citation section 87555(b)(8) was to, ‘Audit all food, and submit proof of completion to CCL by 12/06/2021.’

At 3:28 p.m., the LPAs advised the administrator that 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 files 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. The plan of correction agreed upon for citation section 87412(g) was to, ‘Provide copies of the complete staff files for S1 and S2 to CCL by 12/7/2021.’

On 12/3/2021 at 10:07 a.m., LPA Walker received a text message from Administrator Naira Paroyan inquiring the due date of the plan of correct for citation section 87412(g). Although, the administrator confirmed receipt of copies of the report only one (1) out of (5) citation’s plan of correction have been submitted, and cleared.

During today’s visit, LPA Walker informed the administrator via telephone of civil penalties being assess for to failure to correct deficiencies cited on 12/2/2021. The Administrator was also advised, $100 will be assessed per day until the deficiency is corrected.

In addition, the administrator had provided LPM Pfannenstiel with an updated LIC 500 as requested on November 10, 2021. However, it was observed that the administrator stated on the LIC 500 that she was available from 9 a.m. until 3 p.m., Monday through Sunday. The LPM spoke with the administrator over the phone and confirmed that the administrator was actually only working at the facility from 3 p.m. to 7 p.m., Monday through Sunday. The LPM then requested an updated LIC 500, which has yet to be received. Please provide an updated LIC 500 to LPA Walker by December 13, 2021.

Pursuant to Title 22 California Code of Regulations, Civil Penalties were assessed for Failure to Correct.
Exit interview conducted, today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021

LIC809 (FAS) - (06/04)

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