197610021-9-2-2022-31-AS-MCAA-CHVTCL-20220902143656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610021
Report Date: 09/02/2022
Date Signed: 09/02/2022 02:40:21 PM

Document Has Been Signed on 09/02/2022 02:40 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COMFORT HOME #2		FACILITY NUMBER:	197610021
ADMINISTRATOR:	KANGALA, EMMANUEL		FACILITY TYPE:	735
ADDRESS:	10215 DEMPSEY AVE.		TELEPHONE:	(310) 709-8299
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 4	DATE:	09/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Emmanuel Kangala		TIME COMPLETED:	02:45 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 Analysts (LPAs) Evelin Rios and Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with administrator, Emmanuel Kangala and explained the reason for the visit. At 11:30am, with the assistance of the administrator, 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 throughout the facility that functions properly. The fire extinguisher is located in the kitchen. The fire extinguisher was purchased on 5/12/21. 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 drawer. Properly labeled medications were locked in one of the dining room cabinets. Bedrooms: There were four (4) bedrooms designated for residents' use. All four of bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was between 131.5 and 133 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were properly furnished. The smoke alarms were tested and functional.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
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)

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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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT HOME #2	FACILITY NUMBER: 197610021
	VISIT DATE: 09/02/2022

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry area and detergents are located adjacent to the kitchen. Cleaning supplies, sharps and hazardous items were maintained 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.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
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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Document Has Been Signed on 09/02/2022 02:40 PM - It Cannot Be Edited

Created By: Michael Cava On 09/02/2022 at 12:31 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT HOME #2	FACILITY NUMBER: 197610021
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

This requirement is not met as evidenced by: During the physical plant inspection, the hot water in client bathrooms was measured between 131.5 to 133 degrees.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in two out of two bathrooms sinks were hot water was measured, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2022
	Plan of Correction
1 2 3 4	Prior to the end of the visit, licensee adjusted the hot water heater to insure water temperature measures between 105 to 120 degrees in compliance with regulation.

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:

Eva Miller

LICENSING EVALUATOR NAME:

Michael Cava

LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC809 (FAS) - (06/04)

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