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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236803844
Report Date: 08/13/2021
Date Signed: 08/13/2021 03:11:45 PM

Document Has Been Signed on 08/13/2021 03:11 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:OCEAN SIDE COMFORT CARE LLCFACILITY NUMBER:
236803844
ADMINISTRATOR:BHASKAR, BHUPALAMFACILITY TYPE:
740
ADDRESS:535 E CHESTNUT STREETTELEPHONE:
(707) 409-5004
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 6CENSUS: 6DATE:
08/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Rosalee ReidTIME COMPLETED:
03:30 PM
NARRATIVE
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At approximately 11:45 AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an Annual Required infection control inspection. This inspection will focus on the Infection Control procedures and practices of this facility. LPA met with Kathy Kabai. There were 6 residents present at the facility.

LPA arrived at the facility and did not have temperature checked or health questions asked. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected within the last 12 months. LPA observed 3, 1-gallon bottles of bleach stored on the floor in a resident bathroom. LPA also observed over the counter vitamins accessible, in a resident’s room. LPA observed 1 over the counter melatonin container sitting on top of the medication cabinet and another on a bookshelf in the hallway. The bottles were empty.

Facility Posters are in place at the entrance and throughout the building. The entrance area has a small table with hand sanitizer, thermometer and other items designated for visitors and staff before coming into work or visit. Facility has PPE supplies. Facility has a 30-day supply of medication for clients. Residents do not wear masks inside the facility but have them available.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


Due to technical issues with equipment, a paper copy was not left. A copy of this report was emailed to Licensee. Appeal rights given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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
Document Has Been Signed on 08/13/2021 03:11 PM - It Cannot Be Edited


Created By: Christopher Arnhold On 08/13/2021 at 01:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: OCEAN SIDE COMFORT CARE LLC
FACILITY NUMBER: 236803844

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)

Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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 in 1 of 6 resident rooms. Vitamins were left accessible in a resident room and bleach containers were accessible in a bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2021
Plan of Correction
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Licensee to ensure over the counter medications and cleaning supplies are not accessible to residents in care. Caregiver removed the items from residents access and secured them. Citation cleared at time of visit.
Type A
Section Cited
CCR
87705(j)

The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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 in 2 out of 2 exit doors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2021
Plan of Correction
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Licensee to ensure auditory devices are operational and turned on at each exit door. Licensee to ensure alert devices are installed on each door and are operational. Evidence of installed alert devices to be submitted to CCL by 8/14/2021.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2