306005534-9-30-2022-22-AS-AMEL-CJRN3H-20220930100624

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005534
Report Date: 09/30/2022
Date Signed: 09/30/2022 10:06:27 AM

Document Has Been Signed on 09/30/2022 10:06 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	COMFORT KEEPERS HOME CARE		FACILITY NUMBER:	306005534
ADMINISTRATOR:	MITRICA, CONSTANTIN EMIL		FACILITY TYPE:	740
ADDRESS:	928 ORANGEWOOD DR		TELEPHONE:	(714) 800-9249
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	6	CENSUS: 6	DATE:	09/30/2022
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Constantin Mitrica- Administrator		TIME COMPLETED:	10:15 AM

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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into facility by Constantin Mitrica, Administrator.

At 9:20 AM, LPA toured facility with Constantin Mitrcia, Administrator. Facility has 6 residents present during today’s visit. Facility is a 6 bedroom 3 of which are residents rooms, 3 bathroom 1 of which is a residents bathroom, single story home with a detached garage. LPA observed a screening and sanitizing station at entrance of the facility. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. LPA observed facility has emergency food and water supply. Facility has a secured location for resident medication and files. LPA toured the outside grounds and observed outside visitation areas . Exit gates are unlocked and self latching. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. LPA observed a 4 weeks supply of PPE. LPA reviewed all residents files and all contained required documentation including updated emergency information. Most staff and all residents are vaccinated for COVID-19

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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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