366426081-11-17-2023-56-AS-EMAN-CXSNVV-20231121094831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426081
Report Date: 11/17/2023
Date Signed: 11/17/2023 04:37:33 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/26/2023 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20231026145308

FACILITY NAME:	COMFORT HOME 2		FACILITY NUMBER:	366426081
ADMINISTRATOR:	LAL, HARISH K.		FACILITY TYPE:	740
ADDRESS:	7092 PROVIDENCE WAY		TELEPHONE:	(909) 371-3427
CITY:	FONTANA	STATE: CA	ZIP CODE:	92336
CAPACITY:	6	CENSUS: 4	DATE:	11/17/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Licensee Sue Lal		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff did not protect resident from being hit by another staff.

INVESTIGATION FINDINGS:

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On 11/17/2023 at 01:40 PM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to investigate and deliver findings for the allegation listed above. LPA Brown was greeted and granted entry by a staff member and Licensee Sue Lal was contacted and informed of the visit. LPA Brown explained the purpose of the visit to Licensee Lal. The investigation consisted of observation, interviews, and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that Staff did not protect resident from being hit by another staff. LPA Brown did not find evidence to corroborate the allegation. Interviews with five (5) of five (5) residents indicated that they did not witness a staff or a Home Health Nurse hit Resident #1 (R1) and there’s no incident that happened at the facility that a staff or a Home Health nurse hit a resident. Interviews with three (3) of three (3) staffs revealed they never witness a staff or a Home Health nurse hit R1 or any resident at the facility. ***Continuation in LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20231026145308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2	FACILITY NUMBER: 366426081
	VISIT DATE: 11/17/2023

NARRATIVE

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Staffs #1 (S1), Staffs #2 (S2) and Staff #3 (S3) reported that they were not supervising the Home Health Nurse when they are at the facility to provide care and supervision to R1 but they are available for assistance if needed. S1, S2 and S3 denied witnessing Home Health Nurse hit R1 or any resident at the facility. Home Health Nurse reported to LPA Brown that they never hit R1 and no incident happened at the facility that a Home Health staff hit R1.

Based on interviews and records review, the allegation Staff did not protect resident from being hit by another staff is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to Licensee Sue Lal.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC9099 (FAS) - (06/04)

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