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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850162
Report Date: 12/23/2021
Date Signed: 12/23/2021 09:52:32 AM

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:
12/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Michael Tolentino, StaffTIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies visit to follow up regarding the plan of corrections that were due for submission to CCL by 12/6/21; and 12/7/21. The LPA met with staff Michael Tolentino at 8:39 a.m., and explained the reason for the visit. During today’s visit, the LPA conducted a physical plant tour at 8:42 a.m., to ensure there are no health and safety hazards.

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 were 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 (POC) 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.’ On 12/10/21 at 4:44 p.m., the administrator emailed LPA Walker the Death Report for R1, but no Incident Report has been submitted for R2’s Hospitalization to clear the POC. Therefore, Civil Penalties are being assessed.


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

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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 2
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: 12/23/2021
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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.’ Plan of correction has not been submitted to CCL. Therefore, Civil Penalties are being assessed. 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). Plan of correction has not been submitted to CCL. Therefore, Civil Penalties are being assessed.
On 12/10/2021, LPA 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. As of today, two (2) out of five (5) plan of corrections for deficiencies cited on 12/02/21 have been cleared.
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. LPA Walker requested the administrator please provide an updated LIC 500 to LPA Walker by December 13, 2021. LPA Walker has yet to receive an updated LIC 500. During today’s visit, LPA Walker reminded administrator Naira Paroyan, via telephone, to resubmit an updated LIC 500 reflecting accurate availability.
From 8:52 a.m. until 9:07 a.m., LPA Walker contacted administrator Naira Paroyan via telephone to inform her of civil penalties being assessed for failure to submit plan of corrections cited originally on 12/2/2021. The Administrator was also advised, $100 per day will continue to accrue until the Plan of Corrections have been cleared.
Pursuant to Title 22 California Code of Regulations, Civil Penalties were assessed for Failure to Correct. $100 per day will continue to accrue until the Plan of Corrections have been cleared. Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC809 (FAS) - (06/04)
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