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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610609
Report Date: 08/27/2024
Date Signed: 08/27/2024 11:20:56 AM

Document Has Been Signed on 08/27/2024 11:20 AM - 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 #3FACILITY NUMBER:
197610609
ADMINISTRATOR/
DIRECTOR:		SINGH, RAJPALFACILITY TYPE:
735
ADDRESS:16439 SAN JOSE ST.TELEPHONE:
(310) 709-8299
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 0DATE:
08/27/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Rajpal SinghTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the applicant/administrator, Rajpal Singh. An application to operate an Adult Residential Facility (ARF) was received by Community Care Licensing (CCL) on April 9, 2024. A fire clearance was approved on May 9, 2024 for four (4) ambulatory residents only. The smoke alarms and carbon monoxide detector are dual, and hardwired. The facility has one new fire extinguishers that was purchased on April 26, 2024.

A tour of the physical plant was initiated at approximately 9:50am and the following was observed:

KITCHEN: The facility has a kitchen area that is equipped with a stove, oven, refrigerator and sink. Only a sufficient supply of nonperishable food items is required at this time as there are no residents. There is sufficient dining ware, which includes plates and utensils for the resident's use. Sharps and knives are kept in a locked cabinet.

BEDROOMS: There are four (4) bedrooms designated for the residents use. All four bedrooms are private. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. There are no direct exits from any of the four bedrooms.

BATHROOMS: The facility has two (2) bathrooms. Bedroom #1 has it's own bathroom with toilet and shower. Cleaning supplies will not be maintained in this bathroom. The other bathroom is located in the hallway, by bedrooms #2, #3, and #4. Cleaning supplies will also not be maintained in this bathroom. Both bathrooms were observed to have the proper fixtures and non-skid mats. The hot water delivered in the bathrooms measured at 110 degrees.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMFORT HOME #3
FACILITY NUMBER: 197610609
VISIT DATE: 08/27/2024
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COMMON AREAS: These include the living room, family room and dining room. The living room has two couches, table and television. The family room, which is located adjacent to the living room, has two couches and two chairs. The family room has an exit that leads to the backyard. There is a fireplace that is non-operational and blocked off in the family room. No key or fireplace tools present. There were no visible immediate hazards.

GARAGE: The garage is used for storage and laundry area. There is a washer and dryer in place. Cleaning supplies will be kept locked and inaccessible from the residents in the garage as well. Garage door is kept locked at all times. Entry is from either the front, or from the backyard. No access to the garage from the inside of the facility.

MEDICATIONS: Medications will be kept locked in a kitchen cabinet. First aid kit, first aid manual, and thermometer is also maintained in this cabinet.

STAFF/RESIDENT FILES: Staff and Resident files will be kept locked in one of the hallway closets.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio area with backyard furniture to accommodate the four (4) residents. The facility backyard has sufficient yard space to hold outdoor exercise and activities. There is no swimming pool or bodies of water.

In addition to the Pre-Licensing inspection, a Component III power point presentation was held at the beginning of the visit.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

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

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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