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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607430
Report Date: 03/22/2023
Date Signed: 03/22/2023 07:37:29 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
03/16/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230316084904
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: 4DATE:
03/22/2023
UNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Socorro G Trinidad TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff is not providing adequate food service to residents.
Staff is falsifying staff documents.
Unqualified staff providing care to residents.
INVESTIGATION FINDINGS:
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On 03/22/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit. Upon arrival at the facility, LPA verified the person of COVID-19 activity. Based on the assessment, the facility is cleared of COVID-19 infection. LPA met with Administrator Socorro Trinidad. LPA explained the purpose of today's visit.

The investigation consisted of the following: LPA interviewed staff #1-#3 (S1-S3) and residents #1-#4 (R1-R4). LPA asked questions relevant to the nature of the complaint. A toured the facility inside to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. Personnel Records for (S1-S5)) were provided and reviewed.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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 7
Control Number 11-AS-20230316084904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COMFORT HOME FOR ELDERLY
FACILITY NUMBER: 197607430
VISIT DATE: 03/22/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff is not providing adequate food service to residents.
The details of the complaint reported the staff does not provide adequate food to residents in care. The complainant reported this facility does not have enough food for residents. The Department conducted an inspection visit on 03/22/23 and observed the facility is following Title 22 Section 87555 General Food Services Requirements. The Department observed food supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. The food supply included milk products, meat, vegetables, fruits, bread, cereals, juices, and sweets. A weekly menu was posted and made available for review for residents. Moreover, the facility had an additional food supply stored as a backup freezer inside the facility. Interviews with residents #1-#2 (R1-R2) both confirmed the facility serves three meals daily with snacks and had no issues with the facility not having variety or enough food supply. Due to their health condition, (R3-R4) were interviewed, however unable to provide any information on this matter. According to (S1) groceries are restocked on daily basis. Based on the gathered information, the allegation mentioned above cannot be supported.


Allegation: Staff is falsifying staff documents.
The details of the complaint stated the facility is providing false documentation for staff. The complainant unable to provide further information on this allegation. The Department conducted a review/audited of personnel records, and it revealed the facility had all the required documents for each employee and verified for validity and accuracy. Each staff had the following: Application for Employment, California ID, Heath Screening Report LIC 503, Criminal Record Statement LIC 508, Fingerprint Clearance, Requirement to Report Suspected Abuse SOC 341A, Employee Rights LIC 9052, First Aid Certificate, TB, and Medical Training Verification. Based on the gathered information, the allegation mentioned above cannot be supported.

Evaluation Report continues on LIC 9099-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20230316084904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COMFORT HOME FOR ELDERLY
FACILITY NUMBER: 197607430
VISIT DATE: 03/22/2023
NARRATIVE
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Allegation: Unqualified staff providing care to residents.
The details of the complaint stated that unqualified staff is providing care to residents. The complainant reported that the staff is not fully trained. Interviews conducted with (S1-S3) all verified they have completed all the required medical training. Evidence of training certificates and logs were review/audited. Interviews with residents #1-#2 (R1-2) stated no concerns for the care or supervision. Due to their health condition, (R3-R4) were interviewed, however unable to provide any information on this matter. Based on the gathered information, the allegation mentioned above cannot be supported.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview conducted with Socorro Trinidada and copy of the report provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
03/16/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230316084904

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: 4DATE:
03/22/2023
UNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Socorro G Trinidad TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff did not have a criminal record clearance.
INVESTIGATION FINDINGS:
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On 03/22/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit. Upon arrival at the facility, LPA verified the person of COVID-19 activity. Based on the assessment, the facility is cleared of COVID-19 infection. LPA met with Administrator Socorro Trinidad. LPA explained the purpose of today's visit.

The investigation consisted of the following: LPA interviewed staff #1-#3 (S1-S3) and residents #1-#4 (R1-R4). LPA asked questions relevant to the nature of the complaint. A toured the facility inside to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. Personnel Records for (S1-5)) were provided and reviewed.

Evaluation Report continues LIC 9099
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20230316084904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COMFORT HOME FOR ELDERLY
FACILITY NUMBER: 197607430
VISIT DATE: 03/22/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility staff did not have a criminal record clearance.
The details of the complaint reported that staff employed at this facility do not have background clearance and are not cleared to work. The complainant stated there are undocumented staff are working at this facility. The Department reviewed/audited personnel staff #1-#5 (S1-S5) and it revealed that (S5) does not have a Community Care Licensing (CCL) Criminal Background Clearance Transfer Request LIC-9182 on file and is not associated with this facility. (S5) has been employed at this facility since 10/15/21 and is not included in (CCL) Facility Personnel Report Summary LIS-536 or California Department of Social Services (CDSS) Guardia Background Check System. Based on the information gathered, the allegation listed above is supported.

Based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8 are cited on the attached LIC 9099-D.

An exit interview conducted with Socorro Trinidada and copy of the report provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20230316084904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: COMFORT HOME FOR ELDERLY
FACILITY NUMBER: 197607430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2023
Section Cited
CCR
87355(c)(1)(c)
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87355(c)(1) (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another...to a state licensed facility by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182.
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Licensee to ensure that all staff prior to working in the facility obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by POC due date: 03/23/23.
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This requirement is not met as evidenced by:
Based on (interview) (record review), the licensee did not comply with the section cited above. Staff #5 (S5) did not have criminal record clearance. This poses an immediate health, safety or personal rights risk to persons in care.
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Copies received during the time of visit.
***A CIVIL PENALTY IS BEING ISSUED TODAY***
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7