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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608534
Report Date: 03/18/2022
Date Signed: 03/18/2022 03:39:52 PM


Document Has Been Signed on 03/18/2022 03:39 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ASSISTED COMFORT HOMEFACILITY NUMBER:
197608534
ADMINISTRATOR:MARIAM KEVLIYANFACILITY TYPE:
740
ADDRESS:23731 KILLION STREETTELEPHONE:
(818) 800-9970
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mariam KevliyanTIME COMPLETED:
03:45 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) Elsie Campos arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with the Administrator Mariam Kevliyan at 10:05 a.m. and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with Administrator Mariam Kevliyan at 10:30 a.m., to ensure there are no health and safety hazards.

BEDROOMS: There are (4) four bedrooms designated for resident use and (1) one bedroom designated for staff use. Staff bedroom is part of the attached garage adjacent to the kitchen. Bedroom #3 and Bedroom #4 have a direct exit to the exterior. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. Accessible disinfectants and air freshener were observed in Bedroom #4. Oxygen was observed in Bedroom #1, yet the LPA did not observe the appropriate ‘No Smoking – Oxygen in Use’ sign.

RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. The LPA observed signs in the bathroom attached to bedroom #1 and hallway bathroom promoting good hand hygiene. Restroom hot water measured at 114.3 degrees Fahrenheit at 10:55 a.m.

FILES: During today’s visit, the LPA observed full bed rails on the bed of Resident #1 (R1). The Administrator provided bed rail orders for the resident.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
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 10


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ASSISTED COMFORT HOME
FACILITY NUMBER: 197608534
VISIT DATE: 03/18/2022
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: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and over the counter medications were found in two unlocked drawers. The LPA observed a laundry room with a single turn latch for access located adjacent to the kitchen. Laundry detergents, cleaning supplies and/or toxins are also stored in the laundry area. The laundry room/garage was observed to be unlocked and accessible to residents. All other medications were stored in a locked cabinet. Hot water measured at 113.0 degrees Fahrenheit at 10:47 a.m.

COMMON SPACES: The common spaces included the living room and dining area. At the time of the visit, living room and dining room furniture was observed to be in good condition. Flooring was checked for cleanliness, all areas were clean, sanitary and in good repair. The LPA observed cameras in all common spaces and a screened fireplace in the living room. Smoke detectors and carbon monoxide detectors are hardwired and interconnected. All were tested at 11:12 a.m. and observed to be operational. The fire extinguisher was observed to be full but did not have proof of service or receipt of purchase date. The LPA observed required postings on the wall at the entrance and throughout the facility.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Two storage sheds were observed which included additional oxygen tanks and supplies. There were no bodies of water noted.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator Mariam Kevliyan regarding the facility’s infection control practices. The Administrator was advised that they need to ensure that visitors upon entry are signing in at a central entry point for symptom screening, temperature checks, and sanitation. The facility has a sufficient amount of Personal Protective Equipment (PPE). The Administrator was advised that they may request additional PPE with Licensing if they need it. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.
Exit interview conducted. A copy of the report and appeal rights were provided via Email.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 03/18/2022 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ASSISTED COMFORT HOME
FACILITY NUMBER: 197608534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as two (2) staff were not associated to the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/19/2022
Plan of Correction
1
2
3
4
The licensee agreed to do the following:
1. Associate staff and submit proof to CCL no later than 3/19/22.
Type A
Section Cited
CCR
87705(f)(1)
Criminal Record Clearance
Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee failed to ensure that kitchen knives were inaccessible. During the physical plant tour, LPA observed an unsecured drawer in the kitchen containing knives. This poses an immediate health and safety risk to residents in care.
POC Due Date: 04/08/2022
Plan of Correction
1
2
3
4
The Administrator has agreed to do the following:
1) Move over the kitchen knives into a secured drawer. Plan of correction met at time of visit.
2) Repair magnet lock and submit proof to CCL no later than 4/8/2022.

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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 10


Document Has Been Signed on 03/18/2022 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ASSISTED COMFORT HOME
FACILITY NUMBER: 197608534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

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 as in the facility did not have the required signange posted on the resident door which posed a potential health and safety risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
1
2
3
4
The licensee agreed to the following:
1) Post Oxygen in Use signage on door. Plan of correction met at time of the visit.
Type B
Section Cited
CCR
87203
Care of Persons with Dementia
Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, licensee failed to maintain appropriate fire extinguisher records as the fire extinguisher did not have dates of service or proof of purchase, which poses a potential health and safety risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
1
2
3
4
The Administrator has agreed to do the following:
1) Have the current fire extinguisher serviced or purchase a new one. Submit proof to CCL by 4/8/2022.


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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 10


Document Has Been Signed on 03/18/2022 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ASSISTED COMFORT HOME
FACILITY NUMBER: 197608534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia. (f)The following items shall be made inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 as the kitchen drawer containing over the counter medications was not locked. Magnet lock was not engaging leaving the medications accesible which poses a potential health and safety risk to persons in care.

POC Due Date: 04/08/2022
Plan of Correction
1
2
3
4
The licensee agreed to do the following:
1) Move over the counter medications into a secured drawer. Plan of correction met at time of visit.
2) Repair magnet lock and submit proof to CCL no later than 4/8/2022.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 10 of 10