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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003651
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:11:46 PM


Document Has Been Signed on 06/02/2023 12:11 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:COMFORT COTTAGES #1FACILITY NUMBER:
306003651
ADMINISTRATOR:FAROOQ RASHIDFACILITY TYPE:
740
ADDRESS:25231 MACKENZIETELEPHONE:
(949) 584-7083
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 3DATE:
06/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Farooq Rashid - AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced Case Management - Deficiencies visit to Comfort Cottages #1. During the course of conducting a complaint investigation visit with Complaint Control Number: 22-AS-20230526155220 LPA Velazquez conducted a review of resident records. LPA Velazquez observed the most recent Medical Assessment (MA) for Resident (R) #1 does not document a date of exam but has a physician's signature dated as January 12, 2023 and R1's ambulatory status is listed as Bedridden which was confirmed by Administrator Farooq Rashid, L.V.N. The Medical Assessment for R2 documented a date of exam as January 12, 2023 and R2's ambulatory status is listed as Bedridden which was confirmed by Administrator Farooq Rashid, L.V.N. The facility does not have a Bedridden Fire Clearance which was confirmed by Administrator Farooq Rashid, L.V.N. The facility is licensed for 6 non-ambulatory residents with a hospice waiver for 4 residents which was confirmed by Administrator Farooq Rashid, L.V.N.




Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator Farooq Rashid, L.V.N. and a copy of this report along with the appeal rights, LIC 811, and LIC 9098, were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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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Document Has Been Signed on 06/02/2023 12:11 PM - 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: COMFORT COTTAGES #1
FACILITY NUMBER: 306003651

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2023
Section Cited
CCR
87202(a)(2)

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Fire Clearance. (a) All facilities shall maintain a fire clearance approved by the city, county, or city...or the State Fire Marshal. (2) Bedridden persons. This requirement is not met as evidenced by: based on record review and interview the licensee did not obtain a Bedridden Fire Clearance.
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Licensee to ensure it maintains an appropriate Fire Clearance at all times. Licensee to submit a new Fire Clearance request to Licensing by POC due date. Licensee to complete an LIC 200 and submit it along with a Facility Sketch and a $25
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The MAs for R1 and R2 document both residents as Bedridden and the facility does not have a Bedridden Fire Clearance. This poses an immediate risk to the health and safety of residents in care.

IMMEDIATE CIVIL PENALTY ASSESSED
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check made payable to the Department.

Licensee to submit a written statement to LPA indicating they have read statute and regulation regarding Fire Clearance and how exactly they intend to adhere to it by POC due date.

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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: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2