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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701130
Report Date: 02/21/2025
Date Signed: 02/21/2025 12:38:21 PM

Document Has Been Signed on 02/21/2025 12:38 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COMFORTS OF HOME GAVIRATEFACILITY NUMBER:
342701130
ADMINISTRATOR/
DIRECTOR:		PARAS, FAITHFACILITY TYPE:
740
ADDRESS:9823 GAVIRATE WAYTELEPHONE:
(916) 897-9465
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 4DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Faith ParasTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Faith Paras and explained the purpose of the visit.

LPA Moleski reviewed four resident files (R1-R4) and three staff files (S1-S2 and Paras' file). S1 did not have a health screening or tuberculosis test on file. S2's health screening indicated that they required treatment after a positive tuberculosis test. S2 said they were prescribed antibiotics after the test. No documentation was available to show S2 was free of active, communicable tuberculosis after their antibiotic treatment. Paras' first aid/CPR certification, dated 2/20/23, was expired as of today, 2/21/25. R4 did not have a needs and services plan on file.

While reviewing this facility's medication administration records, LPA Moleski observed many missing signatures for doses of several different medications for more than one resident in the month of February 2025. LPA Moleski reviewed two residents' centrally stored medication records and observed that medication start dates were not recorded, making an audit of dosages impossible. LPA Moleski photographed the record of missing dosages and start dates.

LPA Moleski toured the facility with Paras and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 111 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

While touring this facility, LPA Moleski observed a surveillance camera present in a common area. LPA Moleski asked if the camera captured audio. Paras said it did. LPA Moleski asked Paras if the facility's approved plan of operation permitted the use of video surveillance. [continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COMFORTS OF HOME GAVIRATE
FACILITY NUMBER: 342701130
VISIT DATE: 02/21/2025
NARRATIVE
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After reviewing the plan of operation, Paras said it did not. Paras removed the camera during this visit.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed one staff member (S1) and one resident (R1).

This facility is hereby cited per 22 CCR Sections 87468.2(a)(1), 87465(a)(6), 87411(f), and 87411(c)(1), and HSC Section 1569.695(e)(2). An exit interview was held with Paras. Appeal rights and a copy of this report were left with Paras.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 02/21/2025 12:38 PM - It Cannot Be Edited


Created By: Vincent Moleski On 02/21/2025 at 11:56 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORTS OF HOME GAVIRATE
FACILITY NUMBER: 342701130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.2(a)(1)
"residents in privately operated residential care facilities for the elderly shall have all of the following personal rights ... To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups."

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and interview, the licensee did not ensure residents had a reasonable level of privacy in the common areas of the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2025
Plan of Correction
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2
3
4
Licensee agrees to submit a written plan concerning the future use of video surveillance, such as discontinuance or requesting approval of an updated plan of operation permitting the use of video surveillance, by POC due date. Licensee shall provide a written acknowledgement that audio surveillance is not permitted under any circumstances by POC due date. vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/21/2025 12:38 PM - It Cannot Be Edited


Created By: Vincent Moleski On 02/21/2025 at 12:03 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORTS OF HOME GAVIRATE
FACILITY NUMBER: 342701130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, start dates were not recorded for multiple medications, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/22/2025
Plan of Correction
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Licensee agrees to provide a schedule of planned staff trainings regarding medication documentation by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/21/2025 12:38 PM - It Cannot Be Edited


Created By: Vincent Moleski On 02/21/2025 at 12:03 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORTS OF HOME GAVIRATE
FACILITY NUMBER: 342701130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, one staff member did not have a health screening on file, while another did not possess documentation of tuberculosis clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with S1 and S2's outstanding health screening documents by POC due date.
vincent.moleski@dss.ca.gov

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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/21/2025 12:38 PM - It Cannot Be Edited


Created By: Vincent Moleski On 02/21/2025 at 12:03 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORTS OF HOME GAVIRATE
FACILITY NUMBER: 342701130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review and interview, the facility administrator did not have a current first aid/CPR certification on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with an updated first aid/CPR certification by POC due date.
vincent.moleski@dss.ca.gov
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, a resident did not have a needs and services plan on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with R4's needs and services plan by POC due date.
vincent.moleski@dss.ca.gov
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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