197610021-12-14-2023-31-AS-NRED-CYHTZX-20231214141103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610021
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:11:08 PM

Document Has Been Signed on 12/14/2023 02:11 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 #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:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Kulwant Kaur		TIME COMPLETED:	02:15 PM

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At 11:15 a.m. on 12/14/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and licensee and disclosed the reason for the visit. LPA, administrator, and licensee toured the facility inside and out at 11:45 a.m. No immediate health and safety hazards were observed during this visit.

A file review was conducted prior to today’s visit.

The facility was last visited on 10/18/2023 for a complaint visit. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen. garage, common areas, and outdoor areas. It has an approved fire clearance for four (04) ambulatory residents.

At the main entrance, LPA observed a maintained front driveway. A screening station contained hand sanitizer, digital thermometer, masks, and a visitors log. Postings inside included COVID precautions, confidential complaint contacts, activity schedule, facility license, facility sketch with evacuation routes clearly labelled, personal rights, weekly menu, facility license, and grievance procedure.

The facility has four (04) private bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 11:50 a.m. LPA measured the room temperature to be 77.7 degrees Fahrenheit. The living room contained a television, art supplies, emergency water supply, and exercise equipment. A locked closet contained hygiene supplies. Another closet contained an adequate supply of fresh linens.

The facility has 2 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 12:05 p.m. LPA measured the water temperature in Bathroom #2 to be 115.7 degrees Fahrenheit.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT HOME #2	FACILITY NUMBER: 197610021
	VISIT DATE: 12/14/2023

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All emergency exit paths were free from obstructions. The southern exit gate was unlocked with an inward facing self-closing latch. At approximately 12:10 p.m., the dual-purpose smoke and carbon monoxide detector was tested and operational in Bedroom #3. When tested, three (03) out of three (03) detectors operated simultaneously. At 12:12 p.m. LPA tested the house phone to be operational. At approximately 12:20 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It had a receipt posted form 06/17/2023.

LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator, freezer, and pantry. A menu was posted on the refrigerator. The stove hood was clean. The stove burners were functional. Appliances were in good condition. Sharps and detergents were locked in the laundry room pantry. Medications were locked in the dining room cabinet. Confidential records were locked at the main entrance.

A washing machine and dryer were located near the kitchen. Both were in working order.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition and a maintained backyard. The back yard also had exercise equipment and a locked shed.

The garage was locked and inaccessible. It contained an extra freezer, gardening tools, and paper supplies.

LPA conducted staff and client interviews at 1:00 p.m. and reviewed records at 1:30 p.m.

During today's inspection, the facility was in compliance with Title 22 regulations.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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