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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
366424587
Report Date:
09/11/2023
Date Signed:
09/11/2023 05:52:29 PM
Document Has Been Signed on
09/11/2023 05:52 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
,
1650 SPRUCE ST STE 200 MS29-27
,
CA
92507
FACILITY NAME:
COMFORT HOME RCFE
FACILITY NUMBER:
366424587
ADMINISTRATOR:
LAL, HARISH
FACILITY TYPE:
740
ADDRESS:
7101 VERDUGO PLACE
TELEPHONE:
(909) 349-0998
CITY:
FONTANA
STATE:
CA
ZIP CODE:
92336
CAPACITY:
6
CENSUS:
6
DATE:
09/11/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:45 PM
MET WITH:
Anayeli Hoyos - Care Provider
TIME COMPLETED:
06:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a required annual inspection. LPA identified herself to staff who were advised of the purpose of the visit and S1 phoned licensee Sushma Lal. Licensee Lal arrived shortly and was also informed of the reason for the visit.
The facility is currently licensed as a Residential Care Facility for Elderly, with a capacity of four non ambulatory and two ambulatory residents only. All residents and some visitors are present during today's visit. LPA Bueno and staff Hoyos toured the facility inside while LPA and Licensee toured the exterior of the facility. Licensee left the facility prior to the conclusion of the inspection
Buildings and Grounds:
The home has 5 bedrooms, two bathrooms, a sitting room/office area, a laundry room, a TV/sitting area, and a kitchen and dining area. The facility has no bodies of water. There is a backyard patio with ample seating. LPA and Licensee observed that the side gate is locked but free of obstruction. The facility has a working telephone available for use. There is charged fire extinguisher. S1 tested resident bedroom smoke alarms and LPA tested hallway carbon monoxide detector. LPA and S1 found all units to be in working order.
Storage and Supplies:
Activities were observed to be available near the office area and in the TV are. A locked centralized closet is utilized for medications while client and staff files are secured in the office area. The first aid kit was observed to be available and complete. Linens, and equipment are all in good repair and sufficient for approved census.
Food Service and Laundry:
LPA and S1 observed two days of perishable food items and 7 days of non- perishables. Utensils and dishware are sufficient for the capacity. The refrigerator and stove are in working order. Sharps are kept locked while toxins and cleaning agents are secured in cabinets, inaccessible to residents.
SUPERVISOR'S NAME:
Nedra Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Anna Bueno
TELEPHONE:
951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE:
09/11/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2023
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
7
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:
09/11/2023
NARRATIVE
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Bedrooms and Bathrooms:
Resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. LPA and Licensee observed the water temperature to be 109 degrees Fahrenheit.
Facility Files and Medication:
LPA inspected all resident files and found that it had the required documentation including an admissions agreement and current physician's repor. LPA reviewed three of three staff files with one current first aid certification and two expired. LPA found training records but were not current. LPA reviewed all resident medications and found R1's medication (M1) being administered but is not on the centralized log. Licensee updated personnel report, and will send a current LIC 610E, emergency disaster plan to LPA.
Deficiencies which pose immediate and potential
health, safety or personal rights risk to residents in care.
Refer to LIC809Ds for deficiencies issued during today's visit. An exit interview was conducted by telephone with Licensee and a copy was signed by and provided to S2 at the conclusion of the inspection.
SUPERVISOR'S NAME:
Nedra Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Anna Bueno
TELEPHONE:
951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE:
09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2023
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
09/11/2023 05:52 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
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:
09/11/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and Licensee interview and record review, the licensee did not comply with the section cited above as three of six residents were determined bedridden on their LIC 602, physician's report, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/12/2023
Plan of Correction
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Licensee shall submit an LIC200 to CCL Regional office to request for a capacity change no later than the end of POC day.
Type A
Section Cited
CCR
87202(a)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons... The applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal.
Deficient Practice Statement
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Based on LPA and Licensee interview and record review, the licensee did not comply with the section cited above as three of six residents were determined bedridden on their LIC 602, physician's report, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/12/2023
Plan of Correction
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Licensee shall submit an LIC200 to CCL Regional office to request for a capacity change no later than the end of POC day. Licensee shall maintain communication with the Regional office regarding care for bedridden residents.
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:
Nedra Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Anna Bueno
TELEPHONE:
951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE:
09/11/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2023
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
09/11/2023 05:52 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
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:
09/11/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Licensee observations, the licensee did not comply with the section cited above as LPA and Licensee found an uncovered pot in the garage refrigerator. LPA and Licensee observed that the pot contained some liquid inside, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/18/2023
Plan of Correction
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Licensee shall provide in-service proper food handling and storing to all staff. Licensee shall provide proof of training to CCL Regional office no later than the POC date.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above as LPA found R1's medication (M1) as being administered but not listed on the centralized medication list, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/18/2023
Plan of Correction
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Licensee shall update the centralized medication log to include all medications administered to residents. In addition, Licensee shall provide a current and dated log for medication training.
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:
Nedra Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Anna Bueno
TELEPHONE:
951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE:
09/11/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2023
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
09/11/2023 05:52 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
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:
09/11/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA and S1 observations and Licensee interview, and record review, the licensee did not comply with the section cited as the facility office was converted to a resident bedroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/18/2023
Plan of Correction
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Licensee has submitted an updated floor plan to LPA during the visit. Licensee corrected the aforementioned deficiency during today's visit.
Type B
Section Cited
CCR
87633(b)(6)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and Licensee interview and record review, the licensee did not comply with the section cited above in three out of three staff records did not list training identifying care specific to residents receiving hospice services. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/18/2023
Plan of Correction
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Licensee shall provide appropriate in-service training to all staff providing care to all residents receiving hospice care. Licensee shall provide proof of training and summary of topics covered to CCL Regional office no later than the POC date.
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:
Nedra Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Anna Bueno
TELEPHONE:
951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE:
09/11/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2023
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
09/11/2023 05:52 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
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:
09/11/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observation and Licensee interview and records review, the licensee did not comply with the section cited above in three out of three staff records did not list current training for dementia care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/18/2023
Plan of Correction
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Licensee shall provide appropriate in-service training to all staff providing care to all residents diagnosed with Dementia. Licensee shall provide proof of training and summary of topics covered to CCL Regional office no later than the POC date.
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and S1 observations, the licensee did not comply with the section cited above LPA and S1 found two hammers and screwdriver kit were found in the bottom third cabinet of the kitchen island, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/18/2023
Plan of Correction
1
2
3
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S1 removed the above mentioned items and stored all items in a locked area. This deficiency was immediately corrected at the time of LPA and S1 observations.
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:
Nedra Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Anna Bueno
TELEPHONE:
951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE:
09/11/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2023
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
09/11/2023 05:52 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
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:
09/11/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(l)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Licensee observations, the licensee did not comply with the section cited above as LPA and Licensee were unable to open the side gate due to being locked, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/18/2023
Plan of Correction
1
2
3
4
Licensee shall remove the lock for the side gate latch and subsequently provide a statement of understanding of the California Code of Regulation cited above.
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:
Nedra Brown
TELEPHONE:
(951) 202-5776
LICENSING EVALUATOR NAME:
Anna Bueno
TELEPHONE:
951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE:
09/11/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/11/2023
LIC809
(FAS) - (06/04)
Page:
7
of
7