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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424587
Report Date: 11/29/2023
Date Signed: 11/29/2023 01:52:44 PM


Document Has Been Signed on 11/29/2023 01:52 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 RCFEFACILITY NUMBER:
366424587
ADMINISTRATOR:LAL, HARISHFACILITY TYPE:
740
ADDRESS:7101 VERDUGO PLACETELEPHONE:
(909) 349-0998
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 6DATE:
11/29/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Sushima Lal - LicenseeTIME COMPLETED:
01:54 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced Proof of Correction (POC) visit for deficiencies cited during the facility's recent required annual inspection on 09/11/2023.

During today's visit, LPA reviewed facility records. LPA observed and verified the following:
  • Deficiencies 87204(a) and 87202(a) cited per Title 22 Division 6 of the California Code of Regulations has been cleared. Licensee received a waiver approval for 5 hospice recipients on 9/20/2023. LPA verified that there are no bedridden residents at this facility.
  • Deficiency 87705(l) has been cleared. LPA observed that the side gate is unlocked.
  • Deficiency 87555(b)(23) has been cleared. LPA observed that there are no open containers with food items in the facility refrigerators.
  • Deficiency 87465(a)(6) has been cleared. Licensee complied with the terms of the POC as LPA reviewed completed required annual training, including medication administration.

Letters of Cleared POC were issued during today's visit. This report was reviewed with and a copy was provided to licensee Sue Lal.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
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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