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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610021
Report Date: 10/18/2023
Date Signed: 10/18/2023 12:23:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/10/2023 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20231010120039
FACILITY NAME:COMFORT HOME #2FACILITY NUMBER:
197610021
ADMINISTRATOR:KANGALA, EMMANUELFACILITY TYPE:
735
ADDRESS:10215 DEMPSEY AVE.TELEPHONE:
(310) 709-8299
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 4DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kulwant Kaur, Administrator TIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff did not properly store medication
Facility was in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Angela Panushkina conducted an unannounced complaint visit to this facility to investigate the above allegations. LPAs met with the facility Staff #1 (S1), who granted access to the facility. Administrator arrived shortly after and LPAs explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:10am, LPAs requested resident and staff roster. At 10:20am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan/IPP, etc., relevant to the investigation. At approximately 10:30am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:40am – 11:40pm, LPAs interviewed the Administrator, Assistant Administrator and two (2) staff members. Continue on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/0202
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 31-AS-20231010120039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMFORT HOME #2
FACILITY NUMBER: 197610021
VISIT DATE: 10/18/2023
NARRATIVE
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Allegation: Staff did not properly store medication.
The incident occurred on September 26th, 2023 in the kitchen of Comfort Home #2 facility, when a credible witness observed C3's medication kept in a fridge unlocked and accessible to clients in care. To investigate this allegation, LPAs conducted an interview with the Administrator, Assistant and two (2) staff members. During today’s visit, LPAs confirmed and identified that the facility did not properly store the medication in the refrigerator and it was kept unlocked and accessible to clients in care. In addition, the administrator also admitted the medication error. This is an immediate health and safety risk to clients in care. Based on the information gathered during the visit, the allegation is deemed SUBSTANTIATED.

Allegation: Facility is in disrepair

The incident occurred on September 26th, 2023, when a credible witness observed damaged drawer. To investigate this allegation, at 10:30am, LPAs initiated physical plant tour with the facility Staff #2. During the tour LPAs were unable to determine whether there was anything in disrepair. LPAs conducted an interview with the Administrator, Assistant, and two (2) staff members and they all admitted that the drawer handles in room #1 and #2 were loose/in disrepair however, has since been fixed. Based on the information gathered during the visit, the allegation is deemed SUBSTANTIATED.

Deficiency cited on LIC 9099 D.

Appeal Rights explained. Exit Interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20231010120039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT HOME #2
FACILITY NUMBER: 197610021
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2023
Section Cited
CCR
80087(a)
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Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidence by:
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POC is complete during todays visit
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Based on interviews, the licensee did not comply with the section cited above by having various items througout the facility in disrepair during the visit conducted by the credible witness on 09/26/23, which poses a potential health and safety rist to clients in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20231010120039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT HOME #2
FACILITY NUMBER: 197610021
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
80075(k)(1)
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80075 Health Related Services: (k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible..
This requirement is not met as evidence by:
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Administrator provided copies of the training conducted on 10/12/23.
POC is cleared during todays visit.
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Based on interviews and record reviews, conducted by LPA the licensee did not comply with the section cited above by failing to keep C3's medication locked and inaccessible to clients, which poses an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4