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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603213
Report Date: 10/20/2022
Date Signed: 10/21/2022 08:56:45 AM


Document Has Been Signed on 10/21/2022 08:56 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:COMFORT CARE ASSISTED LIVING FACILITYFACILITY NUMBER:
198603213
ADMINISTRATOR:AVETIKYAN, OLGAFACILITY TYPE:
740
ADDRESS:731 MILFORD STREETTELEPHONE:
(747) 283-6125
CITY:GLENDALESTATE: CAZIP CODE:
91203
CAPACITY:6CENSUS: 6DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Susanna Avetian, House Manager TIME COMPLETED:
12:34 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with House Manager Susanna Avietian and explained the purpose of the visit. Administrator certificate expires January 6, 2023 Last fire drill was on 04/04/2022

Structure:
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 are 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 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 113.2 - 118.2*F.

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· LPAs was screened for this visit.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· 4 client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· 4 client rooms were equipped with alcohol-based hand sanitizer.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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 3


Document Has Been Signed on 10/21/2022 08:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: COMFORT CARE ASSISTED LIVING FACILITY
FACILITY NUMBER: 198603213

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA obseerved 1 PRN (Pataday) for R1, 4 PRN (Vitimin D3, C, A AND B12) for R2 and 5 PRN (Mucinex, Cel Props, Herpecin, Fersosul, and folic acid) for resident 3 without PRN letters and labels which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2022
Plan of Correction
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Licensee will contact phsician for 3 residents and obtain PRN letter, order and place labels on all the PRN in need of and send proof to LPA by POC DATE.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COMFORT CARE ASSISTED LIVING FACILITY
FACILITY NUMBER: 198603213
VISIT DATE: 10/20/2022
NARRATIVE
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· A posted Emergency Disaster Plan was observed posted at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.

· Deficiencies cited per Title 22 Health and safety code, See 809D for details.

Exit interview was conducted with Susanna Avetian, House Manager and a copy of the report was emailed due to printer issues.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3