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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424587
Report Date: 06/20/2022
Date Signed: 06/20/2022 11:17:21 AM


Document Has Been Signed on 06/20/2022 11:17 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:COMFORT HOME RCFEFACILITY NUMBER:
366424587
ADMINISTRATOR:LAL, HARISHFACILITY TYPE:
740
ADDRESS:7101 VERDUGO PLACETELEPHONE:
(909) 349-0998
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 5DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Administrator Sirish LalTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melody Brown arrived at the facility 06/20/2022 at 08:25 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with staff Anayeli Hoyos and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrators Harish Lal and Sirish Lal were contacted and informed of the visit. Staff Hoyos reported that they have five (5) residents at the facility. Administrator Sirish Lal arrived during the visit. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Lal. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing, and signs have been posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect residents from infection during pandemic. However, LPA Brown noticed no central entry point has been designated for universal entry screening, no routine symptom screening like temperature and symptom check has been initiated at entry for all staff, residents and visitors. In addition, LPA Brown observed facility are not documenting daily temperature and Covid-19 symptom checks and any change in condition for staff in order to track spread. Moreover, during the visit, LPA Brown observed two (2) staff not wearing mask while in the facility. LPA Brown will be issuing a Technical Advisory Note for this items. LPA Brown toured the facility's and all rooms and bathrooms have hand soap and paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE. LPA Brown went over the various recommended training for facility staff with Administrator Lal in relation to COVID-19 and Administrator Lal informed LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

**** Continuation in LIC809C ****
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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 9


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: COMFORT HOME RCFE
FACILITY NUMBER: 366424587
VISIT DATE: 06/20/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Lal informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, LPA Brown observed all residents and all staff have been vaccinated and boosted and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their residents, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their residents regularly for any changes in condition and to subsequently notify the residents physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the tour of the facility on 06/20/2022 at 08:45 AM, LPA Brown observed the smoke detectors in bedroom 1, bedroom 2 and bedroom 3 to be non-operable. Licensee was able to obtain a battery for the smoke detector but unable to replace the three (3) non-operable smoke detectors. Administrator Lal reported that she will contact the facility handyman today to replace the three (3) non-operable smoke detectors. LPA Brown informed Administrator Lal that deficiency will be issued as this poses immediate risk to residents in care.


During the visit, LPA Brown requested staff vaccination records and on 06/20/2022 at 09:00 AM, LPA Brown observed all staff have dose 1, dose 2 and booster. Administrator LaL showed proof of vaccinations/booster record to LPA Brown during the visit. In addition, per review of staff records, LPA Brown observed Staff 3 and Staff 6 not associated at the facility. LPA Brown informed Administrator Lal that citation will be issued as this poses potential risk to clients in care.

An exit interview was conducted with Administrator Sirish Lal and a copy of this report (LIC809), LIC 809D, LIC9102 TA Advisory Notes and Appeal Rights were discussed and provided.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 06/20/2022 11:17 AM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: COMFORT HOME RCFE
FACILITY NUMBER: 366424587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fiore and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, the licensee did not comply with the section cited above by having three (3) smoke detectors non-operable in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2022
Plan of Correction
1
2
3
4
Licensee stated to replace three (3) non-operable smoke detectors in the facility and submit proof to LPA Brown by POC due date.
Licensee will submit Statement of Understanding om CCR 87203 to LPA Brown by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 8 of 9


Document Has Been Signed on 06/20/2022 11:17 AM - 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: COMFORT HOME RCFE
FACILITY NUMBER: 366424587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(2)
8735 Criminal Record Clearance. (e) All individuals subject to criminal record review pursuant to BHelath and Safety Code Section 1569.17 (b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section (c)

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not transferring the criminal background clearance of Staff 3 and Staff 6which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2022
Plan of Correction
1
2
3
4
Licensee stated to associate Staff 3 and Staff 6 to the facility and submit proof to LPA Brown by POC due date.
Licensee stated to submit Statement of Understanding on CCR 87355(e)(2) and submit to LPA Brown by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
Page: 9 of 9