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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424587
Report Date: 09/24/2024
Date Signed: 09/24/2024 05:06:12 PM


Document Has Been Signed on 09/24/2024 05:06 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Sushma Lal, AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPAs) LaVette Farlow and Magda Malcore arrived unannounced to conduct the required annual visit to the facility. LPAs were greeted and granted access into the facility by Caregiver Herminia Martinez, and introduced ourselves and stated purpose of the visit. LPAs asked that the administrator be informed of our arrival.

The facility has 5 bedrooms, 2 bathrooms, kitchen, dining area, family room, living room, laundry room, attached garage, and backyard. LPAs completed a walk through of facility and review of records.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 79 degrees fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 109.4 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher. LPAs observed poster on display for personal rights, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets, inaccessible to clients. There was a designated storage space for client/staff files. Medications and first aid kit were in secure cabinets and inaccessible to clients. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions.

Food Service: The facility has a sufficient supply of Non-perishable and perishable food supply for residents in care. Dishes, cups, and utensils were also stored properly. Emergency food and water were observed.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette FarlowTELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: COMFORT HOME RCFE
FACILITY NUMBER: 366424587
VISIT DATE: 09/24/2024
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Yards/Outside: LPAs observed one shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Record Review: LPAs reviewed Administrator and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPAs reviewed client files for admissions agreements, pre-admissions appraisals, physician's reports, and care plans.

No deficiencies were cited during this visit, three (3) technical violations were issued. An exit interview was conducted where this report LIC809 and LIC809C were discussed and copies were provided to Administrator, Sushma Lal.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette FarlowTELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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