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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005075
Report Date: 03/23/2023
Date Signed: 03/23/2023 12:55:11 PM


Document Has Been Signed on 03/23/2023 12:55 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:COMFORTS OF HOME GREENHAVEN RCFEFACILITY NUMBER:
347005075
ADMINISTRATOR:CHAN, JACQUELINEFACILITY TYPE:
740
ADDRESS:6936 GLORIA DRIVETELEPHONE:
(916) 329-8151
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Jesusa PascuaTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 5/9/22 at 1:30PM to conduct an annual inspection visit. LPA met with Caregivers Jesusa Pascua and Romeo Jaspa who are finger print cleared and associated to the facility and explained the purpose of the visit.
Hospice approved for 2 residents of which there are 0 residents receiving hospice services during this visit. Licensing fees are due 5/21/23. Administrator certificate expires 10/25/24 for Jacqueline Chan.

The facility is licensed for a capacity of 6 non-ambulatory residents. LPA observed residents during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. 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.

The temperature inside the facility was observed to be at 71*F which is within the required range of 68-85*F. The hot water temperature was measured at 120.0*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308), current Liability Insurance, Personnel Report (LIC500), Administrator Certificate-Updated

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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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