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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701228
Report Date: 03/20/2023
Date Signed: 03/20/2023 06:58:15 PM


Document Has Been Signed on 03/20/2023 06:58 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:
03/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Teresita AgnanosTIME COMPLETED:
04:15 PM
NARRATIVE
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LPA Lewis made an Unannounced visit to the facility to conduct a case management visit from a complaint that was filed. LPA was met by staff and explained the purpose of the visit. Administrator joined 20 minutes later.

Based on the review of resident files during the complaint investigation the facility does not have a bedridden clearance but had two (2) bedridden residents.


It was learned that R1 required assistance with transferring in/out of bed and to/from R1's wheelchair, toilet, It was learned that R1 was deemed to be bedridden and required assistance with transferring, toileting, and required to be turned/pivoted on set intervals throughout the day and night.

Administrator claims Resident 2 is not bedridden. Will check with hospice and their Physician. LPA and Administrator checked residents file and their 602 (Physicians report) and it does not say the resident is bedridden. The 602 was completed inn August of 2022.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights and a copy of the report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023
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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Document Has Been Signed on 03/20/2023 06:58 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/21/2023
Section Cited
CCR
87202

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87202(a) Fire Clearance. All facilities shall maintain a fire clearance. Prior to accepting persons over 65 years of age and/or non ambulatory persons the licensee shall notify the licensing agency and obtain an appropriate fire clearance. LPA observed that R1 is bedridden.
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 The Licensee agrees to update plan of op and emergency plan as stated in TA.
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This is evidenced by observation. LPA observed that R1 is bedridden.
This poses an immediate risk to resident in care.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023
LIC809 (FAS) - (06/04)
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