306005534-12-9-2024-22-AS-RMRT-DBT2HV-20241209162523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005534
Report Date: 12/09/2024
Date Signed: 12/09/2024 04:26:48 PM

Document Has Been Signed on 12/09/2024 04:26 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	COMFORT KEEPERS HOME CARE		FACILITY NUMBER:	306005534
ADMINISTRATOR/ DIRECTOR:	MITRICA, CONSTANTIN EMIL		FACILITY TYPE:	740
ADDRESS:	928 ORANGEWOOD DR		TELEPHONE:	(714) 800-9249
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:13 PM
MET WITH:	Constantin Mitrica, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 1:13 PM. During today’s visit, LPA met with Constantin Mitrica, Administrator. The facility is a single story home with three shared bedrooms and an approved fire clearance of six non-ambulatory residents; of which one may be bedridden and approved for six on hospice. The facility currently has a census of six residents in care. There are three additional bedrooms where family reside. All our fingerprinted and cleared. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in one resident bathroom, and testing auditory devices on all exits. The hot water temperature measured 109.4degrees Fahrenheit and all smoke and carbon monoxide detectors were operational. The fire extinguisher is charged and was serviced on June 2, 2024. The facility’s last fire drill was conducted on September 30, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. A First Aid kit had all the required elements and a First Aid binder was also on-hand. LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on April 11, 2026. (Continued on LIC 809-C)

Alisa Ortiz	TELEPHONE: (714) 287-4084
RoseMarie Ruppert	TELEPHONE: 714-703-2840
	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COMFORT KEEPERS HOME CARE	FACILITY NUMBER: 306005534
	VISIT DATE: 12/09/2024

NARRATIVE

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(Continued by LIC 809)

LPA observed a shaded seating area outdoors and a grassy area where the facility will be hosting a holiday party next week with residents and their families. In the afternoon residents were in the family room area doing various activities and greeting the Administrator's dog.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Constantin Mitrica, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024

LIC809 (FAS) - (06/04)

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