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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610021
Report Date: 08/15/2024
Date Signed: 08/15/2024 06:27:19 PM

Document Has Been Signed on 08/15/2024 06:27 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 #2FACILITY NUMBER:
197610021
ADMINISTRATOR/
DIRECTOR:		KANGALA, EMMANUELFACILITY TYPE:
735
ADDRESS:10215 DEMPSEY AVE.TELEPHONE:
(310) 709-8299
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:18 PM
MET WITH:Kulwant Kaur - AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
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An unannounced One (1) Year Required visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA met with Licensee Herbert Bagoro and Administrator Kulwant Kaur and explained the purpose of the visit. This is a North LA Regional center (NLARC) vendored facility Level IV-G.

LPA conducted physical plant tour inside and out at 3:38 PM. During the tour, LPA observed that the facility has four (4) private client bedrooms and two (2) bathrooms. One (1) bathroom is designated for staff use. There is no body of water at the facility.

The front main door is the only entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in the bathroom and all over the facility.

The facility had submitted and approved Mitigation and Infection Plan.

Bedrooms were toured and observed to be clean and furnished.
Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature was measured at 117.1°F.
Physical plant was checked for cleanliness and condition. Facility was observed to be generally in good repair and clean during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). The furniture was observed to be in good condition.

(continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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: 08/15/2024
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(continued from 809)

Kitchen area was observed to be clean and sanitary. All disinfectants, cleaning solutions, poisons and sharps were locked in the cabinet located at the far end of the kitchen. Food. The facility is observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.

Fire extinguisher was located at the kitchen, it was observed to be full and last bought on 07/0824. Dual fire and carbon monoxide alarms were observed to be hardwired and interconnected. Alarms were tested and observed to be working.

Garage is attached to the house but has no access from the inside. Garage is currently being used as frozen food, PPE, tools and other toxins storage. Cleaning solutions and laundry detergents are observed kept in the locked laundry cabinet. Laundry room is located adjacent to the kitchen leading to exit in the backyard.

Medication was observed to be locked, inaccessible and stored in the file cabinet in the dining room. Medication records and procedures reviewed with staff. First aid kits were observed to be complete with all the required items.

Client records were reviewed for current IPP (Individual Program Plan) and/or Needs and Service plans, physician report, admission agreements and P & I funds. Client records appeared to be complete and current. Staff records were also reviewed. Staff present have criminal record clearances and associated to this facility. Current training and first aid/CPR observed for staff on duty.

Disaster drill was last conducted on 05/24/24. Required posting observed in facility (complaint hot line poster).

There is no deficiency observed during today's inspection. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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