<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607430
Report Date: 09/26/2022
Date Signed: 09/26/2022 05:18:15 PM

Document Has Been Signed on 09/26/2022 05:18 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:COMFORT HOME FOR ELDERLYFACILITY NUMBER:
197607430
ADMINISTRATOR:SOCORRO TRINIDADFACILITY TYPE:
740
ADDRESS:2729 WESTWOOD BLVD.TELEPHONE:
3104707302
CITY:WESTWOODSTATE: CAZIP CODE:
90064
CAPACITY: 6CENSUS: 5DATE:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Administrator, Socorro TrinidadTIME COMPLETED:
05:15 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
On 9/26/2022, Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool visit to Comfort Home For Elderly. The purpose of today’s visit was to conduct the annual inspection

Upon arriving at the facility, LPA met with Caregivers, Nelly Santiago Salvador and Iris Lorena Cortez. LPA was granted access and allowed to enter facility to conduct an annual inspection. Licensee, Socorro Trinidad joined the visit shortly after. The facility is licensed for 5 non-ambulatory and 1 bedridden. Facility has a hospice waiver for (3) three. The facility currently has 2 ambulatory residents and 3 non-ambulatory residents. 2 ambulatory resident residents are diagnosed with mild Dementia one receives home health and other receives hospice services. The facility does not handle any of the residents’ finances.

During today’s visit LPA toured the single- story physical plant with caregiver, Iris Lorena Cortez, checked food service, reviewed staff records and reviewed resident files for medical status. Reviewed staff records, S#1 is only finger printed but not associated to facility. The facility conducted a fire drill January 2022. The home consists of 5 bedrooms, 2 bathrooms, living room, dining room, kitchen and washer and dryer in hallway closet. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. The water temperature did not measure between the Department’s Regulatory temperature of 105 and 120 degrees F. At 11:54am LPA Alvziar observed the water temperature in bathroom for resident #1 at 129.5 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean; doorways were free of obstructions.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/26/2022
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
Kitchen was checked and LPA Alvizar observed an adequate supply of perishable and non-perishable food. All other hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available with a pair of scissor, tweezer and thermometer. Outside grounds were toured and no bodies of water were observed. There are no security bars or weapons on the premises.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview conducted and a copy of the appeal rights were given Administrator, Socorro Trinidad at the time of the visit.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/26/2022 05:18 PM - It Cannot Be Edited


Created By: Antonia Alvizar On 09/26/2022 at 04:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COMFORT HOME FOR ELDERLY
FACILITY NUMBER: 197607430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in water temperature 129.5 degree F in resident's restroom. Which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2022
Plan of Correction
1
2
3
4
Licensee will adjusted the water heater temperature. Licensee will send a picture of water temperature adjusted by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/26/2022 05:18 PM - It Cannot Be Edited


Created By: Antonia Alvizar On 09/26/2022 at 04:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COMFORT HOME FOR ELDERLY
FACILITY NUMBER: 197607430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviewed, this licensee did not comply with the section cited above in S#1. S#1 which poses/posed a potential health, safety or personal rights risk to persons in care S#1 is only finger printed.
POC Due Date: 10/03/2022
Plan of Correction
1
2
3
4
Licensee will request transfer of criminal record clearance for S#1 not associated with the facility. Licensee will submit proof via -email to LPA by due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5