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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609626
Report Date: 12/08/2023
Date Signed: 12/08/2023 02:46:59 PM

Document Has Been Signed on 12/08/2023 02:46 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
WOODLAND HILLS S.ASC, 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: 4DATE:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Administrator, Kulwant KaurTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Antonia Alvizar conducted an Annual Required visit and inspection of the facility. LPA met with staff, Emmanuel Opolot and shortly after met with Administrator, Kulwant Kaur and explained the reason for the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools.

At 11:00 am, with the assistance of staff, LPA 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 06/12/2023.

Kitchen: The kitchen appliances and fixtures were functional. LPA 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 four (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 two (2) designated for clients' use one (1) for staff. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were properly furnished, functional and clean.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMFORT HOME #1
FACILITY NUMBER: 197609626
VISIT DATE: 12/08/2023
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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: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA 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.

Staff and Residents were also interviewed using the CARE Tools questionnaire.

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 provided to Administrator Mrs. Kaur.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC809 (FAS) - (06/04)
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