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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701228
Report Date: 03/30/2023
Date Signed: 03/30/2023 12:17:57 PM


Document Has Been Signed on 03/30/2023 12:17 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 AC/SC, 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: 4DATE:
03/30/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Teresita AgamanosTIME COMPLETED:
12:30 PM
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On 03/30/2023 at 8:25 AM, Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced to conduct a post-licensing inspection. LPA Lee arrived and was greeted by Caregiver, Teresita Agamanos. LPA Lee asked Caregiver, Teresita to contact the Facility Designated Administrator (FDA) to let them know that Community Care Licensing (CCL) was present at this time. Licensee/FDA Mariam Soumahoro stated that she is in San Francisco and will come to the facility, but if she gets stuck in traffic, then caregiver Teresita Agamanos can assist with the post-licensing visit.

LPA met with caregiver Teresita Agamanos and explained the purpose of the visit. Administrator Certificate # 6049437740 and will expires on 08/22/2024. There are currently four (4) residents currently living at the facility. LPA toured and inspected the physical plant inside and outside with caregiver to ensure there were no health and safety concerns. LPA observed the kitchen, bedrooms, bathrooms, and common areas. LPA
observed the facility is in good repair. LPA observed sufficient furniture and lighting throughout the facility.
LPA observed the rooms to be clean and organized with comfortable furnishings. The hot water temperature
was measured at 112.8 degrees Fahrenheit. The temperature inside the facility measured at 69 degrees Fahrenheit which was within the required range of 68-85 degrees Fahrenheit.
LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a
minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be
locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher and first aid
kits were up to date. Fire extinguisher was last service on 11/07/2022. LPA observed smoke and carbon monoxide detector in the facility were in good repair.
LPA observed the following posted in the entrance of the facility. See Something Say Something poster,
Ombudsman poster, Reporting Requirements, Resident Personal Rights, Evacuation Routes and facility
license was all posted as required.

Report continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COMFORT LIVING ELDER CARE 3
FACILITY NUMBER: 342701228
VISIT DATE: 03/30/2023
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LPA reviewed (2) resident files and (3) staff files, including criminal record clearances. LPA confirmed all residents’ files have required records. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit.

Exit interview held with caregiver and a copy of report given at the conclusion of the visit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
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