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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701228
Report Date: 01/07/2025
Date Signed: 01/07/2025 03:17:20 PM

Document Has Been Signed on 01/07/2025 03:17 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COMFORT LIVING ELDER CARE 3FACILITY NUMBER:
342701228
ADMINISTRATOR/
DIRECTOR:		SOUMAHORO, MARIAM GFACILITY TYPE:
740
ADDRESS:8765 INISHEER WAYTELEPHONE:
(510) 409-7096
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 6DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Alegrine NacarTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 1/7/25 at 1:30pm Licensing Program Analyst (LPA) Kevin Gould arrived at Comfort Living Elderly Care 3 for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Alegrine Nacar and together conducted a tour of the home.

LPA and staff evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor and clean. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed a hole in the closet door in bedroom #1 and the closet door in room #3 is off the rails and not operating as designed.

LPA measured the water temperature, temperature measured at 105 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications. LPA observed insulin stored in the fridge without a lock box and accessible to residents in care. LPA also observed the facility is not disposing of syringes correctly and LPA did not observe syringe disposal in accordance with title 22 regulations. LPA also observed the facility is still pre pouring medications; the medications guide discontinued this practice in 2021.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate.

Per California Code of Regulations, Title 22 the follow deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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 2
Document Has Been Signed on 01/07/2025 03:17 PM - It Cannot Be Edited


Created By: Kevin Gould On 01/07/2025 at 02:48 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: COMFORT LIVING ELDER CARE 3
FACILITY NUMBER: 342701228

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(2)
Maintenance and Operation
(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations and staff statements, the licensee did not comply with the section cited above as facility staff were disposing of used syringes in an exterior garbage receptacle and not an appropriate container which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Licensee has agreed to obtain the correct syringe disposal container by the POC due date. Licensee will provide a written plan of correction indicating the steps all staff will take when disposing of used syringes.
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as LPA observed insulin medications stored in the fridge and not secured in a locked box which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Licensee has agreed to obtain a lock bock to store insulin in the fridge.
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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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