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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701228
Report Date: 12/13/2022
Date Signed: 12/13/2022 01:35:13 PM


Document Has Been Signed on 12/13/2022 01:35 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:COMFORT LIVING ELDER CARE 3FACILITY NUMBER:
342701228
ADMINISTRATOR:SOUMAHORO, MARIAM GFACILITY TYPE:
740
ADDRESS:8765 INISHEER WAYTELEPHONE:
(510) 409-7096
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
12/13/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Susan Nagtalon TIME COMPLETED:
01:45 PM
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Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee arrived unannounced to conducted a Pre-Licensing CHOW Inspection of the facility to ensure compliance with Title 22 regulations. LPA Avelina Martinez and LPA Pang Lee met with Susan Nagtalon, and explained the purpose of today's visit.

Facility has a fire clearance for 6 non-ambulatory residents. Administrator,Mariam G. Soumahoro will be the Administrator of this facility.

LPAs inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. The facility has the required postings, and has Covid-19 postings throughout the facility. The facility has one main Covid-19 screening entry, and log in sheet. The facility has established resident and staff files. In addition, the facility has a first aid it. The facility smoke detectors, carbon detectors, and fire extinguishers are in good repair. The facility has an adequate food supply, and has kitchen utensils. Also the water temperature measured at 120 degrees, and the facility temperature was 75 degrees. The facility has a public telephone, and has an area for activities. Resident bedrooms were furnished, and resident bathrooms were in good repair. Mariam has other licensed facilities, and has completed component 3 prior to this pre-licensing. Component 3 has been waived for this pre-licensing.

The applicant has passed the pre-licensing component of the application process. LPA Martinez will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. An exit interview was conducted, and a copy of this report has been provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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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