195850303-3-15-2024-29-AS-VCOY-D3DTZE-20240315151013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850303
Report Date: 03/15/2024
Date Signed: 03/15/2024 03:10:21 PM

Document Has Been Signed on 03/15/2024 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COMFORT PLACE LTD, THE		FACILITY NUMBER:	195850303
ADMINISTRATOR:	OLUWOLE, KEMI		FACILITY TYPE:	740
ADDRESS:	11905 RIVERSIDE DRIVE		TELEPHONE:	(213) 570-2025
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 6	DATE:	03/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Omowunmi Balogun		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Valeria Conway arrived at 8:52 a.m. to conduct an unannounced annual inspection visit to the above noted facility. At 9:28 a.m. LPA met with Administrator Assistant, Omowunmi Balogun, and explained the reason for the visit. The facility is a one-story facility. At 10:15 a.m., a physical plant tour was conducted inside and out. The facility consists of a total of seven (7) private bedrooms. During today’s visit, LPA observed that resident bedroom #7 which was previously designated as a resident room to be utilized as a staff room. Additionally, the storage room was also designated as a second staff room. LPA discussed these changes with the assistant administrator and requested for an updated facility sketch to be submitted to licensing. All resident rooms have direct exits to the outside. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, a mattress and clean linen. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. All rooms were free of odors. In addition, no bedroom was used as a passageway to another room, bath, or toilet. There are two (2) bathrooms for residents in the hallway and one (1) staff bathroom next to the living/dining room for staff use. The toilet and shower have grab bars and non-skid mats. At 10:41 a.m., LPA tested the hot water temperature in bathroom #1 and read 116.2, and the hot water temperature in bathroom #2 measured at 118.7. Resident and staff records are filed in a filing cabinet which is currently located near the front desk. Medications will be centrally stored in a locked cabinet near the front desk. The first aid supplies were complete, including a current version of a first aid manual. Continued on LIC 9099C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT PLACE LTD, THE	FACILITY NUMBER: 195850303
	VISIT DATE: 03/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099
Kitchen knives are stored in a locked drawer in the kitchen. The supply of dishes, utensils, pots, pans and drinkware is adequate. The supply of perishable and non-perishable food is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen and house cleaning supplies are stored in a locked cabinet located in the kitchen. No flies or other insects were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room which it is screened. There are not working cameras around the common areas and doors have alarms on all exterior doors. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has central air conditioning and are a comfortable range.

The facility smoke alarm system is hard wired. At 11:20 a.m. the smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. Last earthquake and fire drill was done 12/01/2023. There are four (4) fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date. The laundry area is located in the backyard, all laundry detergents are inside a cabinet inaccessible to residents. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a hallway closet. Extra PPE supplies are stored in a storage room next to the main entrance along with emergency water and food. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in common hallway. Other required postings are posted in the common hallway.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT PLACE LTD, THE	FACILITY NUMBER: 195850303
	VISIT DATE: 03/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099-C

The exterior passageways were clean and clear of any obstructions. Patio has a portable umbrella for shade and furniture such as chairs and a table for residents to enjoy. The entire property is fenced, LPA advised Assistant Administrator to change the latch on the main front gate. There is a door with gate with a self-latching mechanism for persons to enter the front yard. There is a locked storage shed in the back yard inaccessible to residents. There no bodies of water on the premises at the present time.

Medication, Staff File and Resident File Review: Not reviewed during today's visit.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3