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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004441
Report Date: 05/28/2021
Date Signed: 05/28/2021 03:29:15 PM

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 CAREFACILITY NUMBER:
347004441
ADMINISTRATOR:JESUSA NAGTALONFACILITY TYPE:
740
ADDRESS:8765 INISHEER WAYTELEPHONE:
(916) 524-2717
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 4DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Staff Luzdeldia Dela CruzTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Anthony Tuck Island arrived to conduct an unannounced annual/random inspection on 05/28/2021. LPA met with staff: Luzdeldia Dela Cruz and explained the purpose of the visit. Jesusa Nagtalon is the Administrator and holds certificate #6004452740 that expires on 05/02/2023.

This facility is a single story building licensed to serve six (6) non-ambulatory residents and a hospice waiver up to (3). LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (106.5) degrees Fahrenheit in kitchen sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke detectors are in compliance with fire safety. Fire extinguisher last serviced February 22 of 2021. Thermostat was observed at 78 degees Fahrenheit.

LPA observed centrally stored medications and toxins was kept locked and inaccessible to clients. LPA observed clients medication baskets. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.
The following forms need updating and submitted to CCLD by 06/01/2021:
LIC 500

LPA requested a copy of Administrator Certificate
LPA found no deficiencies during today's visit.
Exit interview held with Administrator Jesusa Nagtalon and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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