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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606703
Report Date: 05/17/2022
Date Signed: 05/17/2022 01:56:26 PM


Document Has Been Signed on 05/17/2022 01:56 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:COMFORT AND CARE FOR THE ELDERLYFACILITY NUMBER:
300606703
ADMINISTRATOR:LAYTON, PILARFACILITY TYPE:
740
ADDRESS:24052 CARRILLO DRIVETELEPHONE:
(949) 690-4631
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
05/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Administrator Pilar Layton TIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an announced case management visit to this facility. LPA met with Administrator (AD) Pilar Layton; and stated the purpose of this visit.

LPA Marin toured the interior of the facility and observed six residents and two staff members on the floor.

On February 22, 2022, Community Care Licensing Division (CCLD) Orange Office received a letter from AD Layton requesting for an increase in hospice waiver to four. LPA reviewed the supporting documents and compliance history of the facility. On March 14, 2022, Licensing Program Manager Luz Adams approved the increase in hospice waiver to four.

For this visit, LPA discussed the Title 22 Division 6 California Code of Regulations Section 87633. Hospice Care for Terminally Ill Residents. AD Layton agreed to review the hospice care plan and ensure all the needs of the residents are met while under hospice care. AD agreed to document training being provided and necessary to the care of resident under hospice care. AD also agreed to notify the local fire department in a event that one of the residents under hospice care become bedridden due to advancing medical condition; and to document such reporting.

LPA also discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that an support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

LPA gave the general email address of the office: CCLASCPOrangeCountyRO@dss.ca.gov AD can send incident reports and other general documents through this email.

For this visit, no deficiency noted for areas observed.

LPA Marin completed an exit interview with AD; and copies of this report, approved letter for increase in hospice waiver and updated license were left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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