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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426081
Report Date: 03/06/2024
Date Signed: 03/06/2024 12:08:54 PM


Document Has Been Signed on 03/06/2024 12:08 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 2FACILITY NUMBER:
366426081
ADMINISTRATOR:LAL, HARISH K.FACILITY TYPE:
740
ADDRESS:7092 PROVIDENCE WAYTELEPHONE:
(909) 371-3427
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 5DATE:
03/06/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Anayeli HoyosTIME COMPLETED:
12:30 PM
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On 03/06/2024 at 11:30 AM, Licensing Program Analysts (LPAs) Melody Brown and Paola Guerrero made an announced visit to the facility to amend the form LIC809D issued on 02/28/2024 due to computer error. LPA Brown met with a staff and was granted entry to the facility. Licensee Sushma Lal was contacted and informed of the visit. At the time of the visit there's (1) staff present, and five (5) residents present.

During this visit, LPA Brown amended the form LIC809D issued on 02/28/2024 due to computer error and issued a new form LIC809D for Postural Supports 87608(a)(3) as Resident #1 (R1), Resident #3 (R3) and Resident #5 (R5) have half bed rails without their physician order indicating the need for half bed rail for mobility. Also, a civil penalty of $250.00 will be assessed as the facility was cited for the same violation within 12-months period.

An exit interview was conducted, and this report (LIC809), LIC809D, and Appeal Rights were discussed and provided to Licensee Sushma Lal.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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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Document Has Been Signed on 03/06/2024 12:08 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 2
FACILITY NUMBER: 366426081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
87608(a)(3)

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87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency... This requirement is not met as evidenced by:
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Licensee stated to obtain doctor's written order indicating the need for half bed rail for R1, R3 and R5 and submit proof to LPA Brown at Plan of Correction (POC) due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Resident #1 (R1), Resident #3 (R3) and Resident #5 (R5) have half bed rails without their physician order indicating the need for half bed rail for mobility in their facility file which poses a potential health, safety or personal rights risk to persons in care.
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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: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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