<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701228
Report Date: 03/27/2023
Date Signed: 03/27/2023 10:29:03 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2023 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230203170904
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:
03/27/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Teresita AgnanosTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident developed pressure injuries due to staff not turning resident as needed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Lewis made an Unannounced visit to the facility to deliver findings on the allegations listed above. LPA was met by staff and explained the purpose of the visit.

Based on Hospice notes dated in January 2023 and staff interviews allegation is Substantiated.
The Department has investigated the compliant and determined the allegation is Substantiated.

As a result of this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. A civil penalty in the amount of $500 is being issued on today's visit due to the violation resulting in an unstageable wound. Failure to correct the deficiency may result in additional civil penalties.

At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code ยง 15610.67 Appeal rights were provided.


Exit interview was conducted and a copy of this report was given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2023 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230203170904

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:
03/27/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Teresita AgnanosTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not ensuring that resident's bed guardrails do not pose a hazard to resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Lewis made an Unannounced visit to the facility to deliver findings on the allegations listed above. LPA was met by staff and explained the purpose of the visit.

The Department has investigated the compliant and determined the allegation is Unsubstantiated.

Therefore, the allegationStaff are not ensuring that resident's bed guardrails do not pose a hazard to resident, is Unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted and a copy of this report was given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2