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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800194
Report Date: 10/09/2023
Date Signed: 10/09/2023 12:16:10 PM


Document Has Been Signed on 10/09/2023 12:16 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:COMFORT SENIOR VILLA INCFACILITY NUMBER:
331800194
ADMINISTRATOR:AGUINALDO, KRISTENFACILITY TYPE:
740
ADDRESS:32841 PITMAN LANETELEPHONE:
(951) 246-2273
CITY:MENIFEESTATE: CAZIP CODE:
92584
CAPACITY:6CENSUS: 0DATE:
10/09/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Kristen AguinaldoTIME COMPLETED:
12:16 PM
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An Informal Meeting was conducted today in the Riverside Adult and Senior Care Office. The purpose of the Informal Meeting was to discuss recent notification of facility closure and change of location. Present at today’s meeting were, Regional Manager Reyna Lacey and Licensing Program Manager Rikesha Stamps, and Facility Administrator Kristen Aguinaldo.

The informal meeting process was explained to the Administrator. During the meeting, Regional Manager requested copies of eviction notices sent to the families, physicians reports, emergency contact sheets, and a needs and services plans of residents who were in care prior to them relocating. Title 22 regulations section 87224 was discussed to ensure Administrator Kristen has knowledge of Eviction Procedures. Details regarding the date the licensee vacated the property were obtained and dates residents were evicted were obtained.

A Stipulation and Waiver; and Order effective 08/30/23 was discussed with Kristen to ensure substantial compliance and department expectations have been met. A copy of the A Stipulation and Waiver; and Order was provided to Administrator Kristen Aguinaldo.

Regional Office advised that the change of application submitted to the department will be discussed with the Centralized Application Bureau.

An exit interview was conducted, and a copy of this report were provided to the Administrator Kristen Aguinaldo at the conclusion of the meeting.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Rikesha StampsTELEPHONE: (818) 248-0313
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023
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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