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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607430
Report Date: 04/14/2022
Date Signed: 04/14/2022 03:17:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2022 and conducted by Evaluator Troy Agard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220215130330
FACILITY NAME:COMFORT HOME FOR ELDERLYFACILITY NUMBER:
197607430
ADMINISTRATOR:SOCORRO TRINIDADFACILITY TYPE:
740
ADDRESS:2729 WESTWOOD BLVD.TELEPHONE:
(310) 470-7302
CITY:WESTWOODSTATE: CAZIP CODE:
90064
CAPACITY:6CENSUS: 5DATE:
04/14/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gladys Villalta, Caregiver TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility is not following COVID-19 protocols.
Medication closet was left unlocked on multiple occasions.
INVESTIGATION FINDINGS:
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On 04/14/2022 Licensing Program Analyst (LPA) Troy Agard conducted an initial complaint investigation at the above facility to address the following allegations. LPA Agard was met with Gladys Villalta, Caregiver and explained the purpose of the visit was to gather information regarding this complaint.

The investigation consisted of the following: LPA conducted an inspection, toured the facility, and conducted interviews. LPA requested the following records: Staff and resident roster, mitigation plan, any related trainings.

On 04/14/2022, LPA Agard delivered findings.

Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20220215130330
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COMFORT HOME FOR ELDERLY
FACILITY NUMBER: 197607430
VISIT DATE: 04/14/2022
NARRATIVE
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Regarding the allegation: Facility is not following COVID-19 protocols. “During a facility visit, the ombudsman did not have their temperature checked prior to entering the facility or answer screening questions related to COVID-19. Additionally, ombudsman observed that none of the caregivers were wearing a face mask when interacting with the residents.” The investigation revealed the following: S1 confirmed the allegation as true. “Here’s the thing, when the ombudsman came, they were complaining that no one was wearing a mask or checking the temperature, but no one comes to the house, except for the nurse. The staff have all been informed that they must wear their mask at all times moving forward.” S2 generally states they were reminded by S1 that they must wear their mask at all times.
LPA was unable to interview residents R2-5 due to communication barriers.

Regarding the allegation: Medication closet was left unlocked on multiple occasions. “Ombudsman observed that the medication closet where the medications are kept was open and unlocked as the doorknob had a pair of keys inside.” The investigation revealed the following: S1 confirmed the allegation to be true. “The first time they came I was cleaning the backyard and they asked me where my mask was. I told them; it was so hot. I’ am by myself in the backyard cleaning. I’m more than 15 feet away. That’s also when he saw the cabinet open because I had just got something from there. I was going to return back what I got out of the cabinet and then they came. They showed up.”

During a review of facility mitigation plan, it states the facility will do the following: have a visitation plan in place, check temperatures, have signage posted, require face mask. Facility failed to follow covid mitigation protocol by allowing staff to interact with residents without a mask and not screening visitors.

Based on the interviews conducted with administrator and their confirmation of both allegations, the preponderance of evidence standard has been met, therefore the above allegations is found to be Substantiated. California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D.

An exit interview was conducted with caregiver and a hard copy was provided with appeal rights.

See LIC 9009-D on the next page.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20220215130330
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COMFORT HOME FOR ELDERLY
FACILITY NUMBER: 197607430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Facility will retrain all staff on mitgation plan and submit proof to Analyst by POC due date.
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This requirement was not met as evidenced by: Based on administrator admitting to themselves and staff not wearing a mask during a visit from the LTCO. which presented a potential health and safety risk to resident in care.
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Type B
04/21/2022
Section Cited
CCR
87307(b)
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87309 Storage Space Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above.
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Facility will have all staff reviews regulation and submit proof to Analyst by POC due date.
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This requirement was not met as evidenced by: Based on administrator admitting to themselves and staff were not ensuring medication was locked and inaccessible to residents in care. Which presented a potential health and safety risk to resident 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.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3