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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423907
Report Date: 01/23/2024
Date Signed: 01/23/2024 12:09:29 PM


Document Has Been Signed on 01/23/2024 12:09 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:COMFORTS OF HOME RESIDENTIAL CARE, LLCFACILITY NUMBER:
336423907
ADMINISTRATOR:CORI COOPERFACILITY TYPE:
740
ADDRESS:74-092 JERI LANETELEPHONE:
(760) 610-1156
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY:6CENSUS: 6DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Cori CooperTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Administrator, Cori Cooper who was informed of the purpose of the visit. At time of visit there were (6) clients and (2) staff present.

The facility is a one story home with (4) bedrooms and (3) bathrooms with attached garage. The facility does have a pool which has a locked gate surrounding it. No fire arms are kept at the facility. The facility is designated as a residential facility for the elderly serving elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents, and observed the following:

Infection Control: LPA observed hand hygiene supplies, PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has an infection control plan that is documented with the department, however the administrator was unable to provide it during the visit for review. Technical note was documented for this.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The carbon monoxide detector was operational during the visit.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: COMFORTS OF HOME RESIDENTIAL CARE, LLC
FACILITY NUMBER: 336423907
VISIT DATE: 01/23/2024
NARRATIVE
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Record Review and Resident/Staff Files: LPA reviewed staff files, training, and criminal clearance. LPA met with Staff #1 (S1) who was not on the staff roster, and was alone with residents. LPA checked S1's criminal record clearance during the visit, who possesses a cleared background. The administrator was able to show LPA S1's file during the visit, and was informed that S1 had started (4) days ago. S1 needs completed physical, orientation training and completed transfer. Deficiencies were cited and plan of correction was created with administrator.

Client files were reviewed and possessed all required paperwork. Client #1 (C1) had LIC602 that was not dated or signed by a physician. Technical note was documented for this to be completed. Admission agreement for C1 was not signed by facility representative. Administrator signed the agreement during the time of the visit. Technical note was documented for this as well.

Health Related Services/ Incidental Medical Services: All client medication was locked in a kitchen cabinet. LPA reviewed client medications for C1 and found medication for today's date was not initialed as given. LPA also found PRN medications for C1 did not have a physician's order with C1's medical provider. Deficiency was cited for this and plan of correction was created with administrator.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA was informed by administrator that the last drill was conducted October 2023, documentation was unable to be provided during the time of the visit for the drill. Deficiency was cited and plan of correction was created for drill to be conducted and documented.

An exit interview was conducted where a copy of this report, along with deficiency pages, appeal rights, and technical notes were provided to Administrator, Cori Cooper.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 01/23/2024 12:09 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: COMFORTS OF HOME RESIDENTIAL CARE, LLC
FACILITY NUMBER: 336423907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with S1 who was cleared but did not have a transfer for the fcility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2024
Plan of Correction
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The administrator provided a transfer to the LPA during the time of the visit. The administrtor agreed to send the LPA LIC500 showing that sufficent staff coverage exist for staff that are fingerprint cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 01/23/2024 12:09 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: COMFORTS OF HOME RESIDENTIAL CARE, LLC
FACILITY NUMBER: 336423907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(1)
Incidental Medical and Dental Care Services
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with MARS log that was not initaled for C1, and PRN medication that did not have a physican's order for C1 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
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The administrtor agreed to send the LPA the orders for the PRN medication by the POC due date for C1.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with drill that was due december and has not been yet conducted. Documentation was unable to be provided for last drill in October 2023 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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The administrtor stated theywould conduct a drill by the end of the month and send the documentation to the LPA by the POC due date.
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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8