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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 374700066
Report Date: 06/17/2024
Date Signed: 06/17/2024 11:17:53 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/17/2024 11:17 AM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:COMFORT KEEPERS # 521FACILITY NUMBER:
374700066
ADMINISTRATOR/
DIRECTOR:		BASSOLA, GEORGEFACILITY TYPE:
300
ADDRESS:830 ORANGE AVE STE J2TELEPHONE:
(619) 435-6318
CITY:CORONADOSTATE: CAZIP CODE:
92118
CAPACITY: CENSUS: DATE:
06/17/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Monique FloresTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Home Care Services Bureau (HCSB) Analyst Adrian Mangina arrived at the business office of Comfort Keepers #521 on 6/17/2024 for a Biennial inspection. Upon arrival, the HCSB analyst identified herself and was greeted by Scheduler Alicia Griece. Designee Monique Flores arrived approximately 15 minutes later. The proper posting of business hours and license were observed. The analyst was shown to an area where the review of personnel and administrative files could be performed. Designee provided current Liability and worker's compensation insurance and dishonesty bond. Upon completion of the file review the analyst discussed the findings of the inspection with the Ms. Flores. The analyst informed the representative named above of the deficiencies found and explained they would be noted on the HCS809-D forms. In addition, the Designee was provided a copy of the HCS9058 Appeal Rights form.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2024 11:17 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 06/17/2024 at 10:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814

FACILITY NAME: COMFORT KEEPERS # 521
FACILITY NUMBER: 374700066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2024
Section Cited
1796.45
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1796.45(c) …After submitting to an examination, an affiliated home care aide whose test for tuberculosis infection shall be required to undergo an examination at least once every two years...
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This requirement was not met as evidence by:
During the review of files, it was observed that reference #4 did not have current TB test results, a finding which poses an immediate health and safety 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.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/17/2024 11:17 AM - It Cannot Be Edited


Created By: Adrian L Mangina On 06/17/2024 at 10:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814

FACILITY NAME: COMFORT KEEPERS # 521
FACILITY NUMBER: 374700066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2024
Section Cited
1796.44
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1796.44 A home care organization licensee shall ensure that prior to providing home care services, an affiliated home care aide shall complete the training requirements specified in this section... a minimum of five hours of annual training.
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This requirement was not met as evidence by:
During the review of files, it was observed that reference #2, #4, and #6 did not have current annual training, a finding which poses a potential health and safety 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.
LICENSING EVALUATOR NAME: Adrian L Mangina
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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