331800194-1-25-2023-18-AS-JARA-CNER6Y-20230125114531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800194
Report Date: 01/25/2023
Date Signed: 01/25/2023 11:48:03 AM

Document Has Been Signed on 01/25/2023 11:48 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	COMFORT SENIOR VILLA INC		FACILITY NUMBER:	331800194
ADMINISTRATOR:	AGUINALDO, KRISTEN		FACILITY TYPE:	740
ADDRESS:	32841 PITMAN LANE		TELEPHONE:	(951) 246-2273
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92584
CAPACITY: 6		CENSUS: 6	DATE:	01/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Staff, Emilia Ancheta		TIME COMPLETED:	12:00 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) Janira Arreola, made an unannounced visit on 01/25/2023 at 09:50 a.m. in order to conduct an annual visit with a focus on infection control. LPA met with staff, Emilia Ancheta, who was informed of the purpose of the visit. LPA called the administrator Kristen Aguinaldo over the phone. At the time of the visit there were ( 3) staff and (6) residents present. LPA proceed to conduct a walk through of the facility's interior and exterior. LPA observed there was a central entry point where screenings are conducted for facility visits. LPA observed COVID-19 postings at the facility. The facility has PPE that is readily accessible to staff and residents. LPA observed the resident bedrooms that would be used as isolation rooms. The resident bathrooms were observed to be clean and have the appropriate hand hygiene supplies. The facility has a cleaning plan in place to disinfect and clean the high touch surfaces of the facility. The staff have leave in case of contact or testing positive for COVID-19. The staff have been trained on how to properly don and doff the PPE equipment, and there is a plan of care in place to attend to those residents that would be in the isolation rooms. Administrator informed LPA that staff have not been FIT tested for an N95 respiratory. LPA will document technical advisory note for this. The LPA also observed that the PPE was not at a 30-day supply. The LPA will document a technical advisory note for this. LPA conducted a visit to the facility. A Resident #1 (R1) had opened the facility door, and LPA observed that the (2) staff on duty were not with the residents in the main home at the time. Staff #1 (S1) was upstairs, and Staff#2 (S2) was outside in a detached room attending to another resident. LPA observed (2) residents, R1 and Resident #2 (R2), ambulating around facility with no staff supervision. LPA informed the administrator of this. LPA advised administrator that staff must present at all times in order to supervise residents. When a staff is outside, another needs to be aware of the residents in the home. The remainder of the visit, LPA observed staff were present with the residents.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COMFORT SENIOR VILLA INC	FACILITY NUMBER: 331800194
	VISIT DATE: 01/25/2023

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
26
27
28
29
30
31
32

LPA was observed (4) bottles of cleaners under the bathroom sink that were left unattended and unlocked. LPA informed S1 who placed these cleaners in a locked area in the garage. This poses an risk to the residents in care. This will be documented on an LIC809-D page along with a plan of correction.

An exit interview was conducted where this report was reviewed and provided to Staff, Emilia Ancheta.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 01/25/2023 11:48 AM - It Cannot Be Edited

Created By: Janira Arreola On 01/25/2023 at 11:02 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COMFORT SENIOR VILLA INC	FACILITY NUMBER: 331800194
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above with (4) bottles of cleaner that were found unattended in the facility bathroom. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/26/2023
	Plan of Correction
1 2 3 4	Administrator stated they would retrain their staff on proper storage of cleaning supplies. The administrastor will submit to LPA copy of training material used and staff signatures acknowleging that have understood what is included in the training material. This shall be submitted to LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6