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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609626
Report Date: 09/02/2022
Date Signed: 09/02/2022 11:12:24 AM

Document Has Been Signed on 09/02/2022 11:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:COMFORT HOME #1FACILITY NUMBER:
197609626
ADMINISTRATOR:KANGALA, EMMANUELFACILITY TYPE:
735
ADDRESS:10156 COLLETT AVETELEPHONE:
(310) 709-8299
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: DATE:
09/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Emmanuel KangalaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPAs) Michael Cava and Evelin Rios conducted an Annual Required visit and inspection of the facility. LPA met with staff, Dennis Mugume and shortly after met with Emmanuel Kangala and explained the reason for the visit.

At 9:30am, with the assistance of staff, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are hardwired and interconnected. There are carbon monoxide detectors that functions properly. The fire extinguisher is located in the entrance of the kitchen. The fire extinguisher was purchased 8/31/2021.

Kitchen: The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the laundry room. Properly labeled medications were locked in one of the kitchen cabinets.

Bedrooms: There were six (4) bedrooms designated for clients' use. Four of the bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are three (3) bathrooms total (2) designated for clients' use (1) for staff. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 108 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were properly furnished.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMFORT HOME #1
FACILITY NUMBER: 197609626
VISIT DATE: 09/02/2022
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Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards. The laundry area and detergents are located by the kitchen. Cleaning supplies are kept in a locked cabinet in the laundry room.

Resident Files: LPAs conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPAs also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
LIC809 (FAS) - (06/04)
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