198603213-9-30-2021-28-AS-NMAN-C7CS5Z-20210930133511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603213
Report Date: 09/30/2021
Date Signed: 09/30/2021 01:35:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	COMFORT CARE ASSISTED LIVING FACILITY		FACILITY NUMBER:	198603213
ADMINISTRATOR:	AVETIKYAN, OLGA		FACILITY TYPE:	740
ADDRESS:	731 MILFORD STREET		TELEPHONE:	(747) 283-6125
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91203
CAPACITY:	6	CENSUS: 5	DATE:	09/30/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Susanna Avetian - Manager		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPA met with Facility Manager Susanna Avetian who assist with the visit. The purpose of the visit was explained. The facility is licensed to serve 6 (six) non-ambulatory residents ages 60 and over of which 1 (one) may be bedridden and facility is approved to retain 4 residents on hospice. The facility cares for elderly resident with dementia.
LPA Nune Margaryan inspected the physical plant including but not limited to the kitchen, dining / living room, resident's bedrooms, resident's bathrooms, laundry area, and outside areas of the facility to ensure compliance with Title 22 regulations. The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted at the front door and throughout the facility. LPA also conducted the infection control domain tool.

Facility is a one story family home with four (4) bedrooms, two (2) full bathrooms, one (1) 1/2 bathroom; living room / dining area, and kitchen. There is a small office located next to front door. Staff and residents files locked and inaccessible. Bedrooms 1, 2 and 4 have direct exits. All exits are equipped with auditory devices with alert feature to monitor exits. Front yard landscape is in good condition at time of visit. Washer/Dryer appliances are located in laundry area. Bedrooms #1, 2, 3, and 4 are approved for non-ambulatory clients and bedroom # 1, 2, or 4 can be bedridden. All bedrooms are clean and completely furnished. The bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested throughout the facility and maintained within the required range of 105-120*F.

Continued 9099C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COMFORT CARE ASSISTED LIVING FACILITY	FACILITY NUMBER: 198603213
	VISIT DATE: 09/30/2021

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Exits and passageways were free of obstructions. The common areas (dining / living room) clean and properly furnished.

The kitchen was observed for the ability to prepare and serve food. Kitchen knives are stored in a locked cabinet in the kitchen. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Cleaning solutions are kept locked and inaccessible.

The first-aid kit was observed and found in compliance. Fully charged fire extinguisher is located in the dining room. The backyard has a shaded area with patio furniture. There is no pool or other large bodies of water. Exits and passageways were free of obstructions.

Per California Code of Regulations, Title 22, deficiencies were not observed during the visit. Exit interview conducted and a copy of the report were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC809 (FAS) - (06/04)

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