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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607430
Report Date: 08/08/2024
Date Signed: 08/08/2024 02:35:14 PM


Document Has Been Signed on 08/08/2024 02:35 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:Socorro Trinidad, AdministratorTIME COMPLETED:
03:00 PM
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On 08/08/2024 at 1:00 pm Licensing Program Analyst (LPA), David España conducted an unannounced annual visit using the full CAREs tool. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection. LPA was met by Socorro Trinidad Administrator and the purpose of today’s visit was explained.

The facility is licensed to serve (6) residents ages 60 and above of which (5) may be non-ambulatory and (1) bedridden. Facility has an approved hospice waiver for (4) residents. The facility is located in a residential neighborhood it consists of 5 bedrooms, 2 bathrooms, living room, dining room, kitchen and washer and dryer in hallway closet and patios with shaded areas. LPA toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (5) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LIC809-C (cont).

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: COMFORT HOME FOR ELDERLY
FACILITY NUMBER: 197607430
VISIT DATE: 08/08/2024
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LPA inspected rooms: #1, #2, #3 #4 and #5 and smoke and carbon monoxide combo are all operable conditions. The water temperature properly measured between 105°-120°F. LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable.

A review of (5) residents' service files, (2) staff personnel files and (2) Medication Administration Records (MAR) were checked. First AID kit was checked. LPA observed the facility's infection control practices. Licensee will email copy of liability insurance to LPA.

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Socorro Trinidad Administrator.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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