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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600011
Report Date:
11/05/2024
Date Signed:
11/05/2024 04:44:51 PM
Document Has Been Signed on
11/05/2024 04:44 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 BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
COMFORT HOME II
FACILITY NUMBER:
415600011
ADMINISTRATOR/
DIRECTOR:
CAINGCOY, RUFINA
FACILITY TYPE:
740
ADDRESS:
652 VANESSA DRIVE
TELEPHONE:
(650) 349-0843
CITY:
SAN MATEO
STATE:
CA
ZIP CODE:
94402
CAPACITY:
6
TOTAL ENROLLED CHILDREN:
0
CENSUS:
5
DATE:
11/05/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:
Jennilee Patalot
TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds--including detached storage shed--for this 6 bed RCFE, consisting of 5 client bedrooms, staff room with 1 bed, 2 full bathrooms, kitchen, living/dining room, office/storage room, and 1-car garage. The backyard is level, fenced and paved. Washer and dryer are located outside of kitchen in covered alcove. There are no accessible bodies of water or fire safety hazards observed. Hot water temperature is tested in common bathroom. Food supply and first-aid kit are inspected, and hygiene items for general use are maintained. Client files are reviewed. An Emergency Disaster Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as required staff records. There is one resident receiving hospice services at this time.
There are no RCFE certified administrators associated with facility: Rufina Caingcoy and Jenilee Patalot have expired RCFE administrator certifications.
The following forms are requested to be completed and returned to CCL by 10/29/24:
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. See also Technical Advisory Notes--6 pages.
April Cowan
TELEPHONE:
(650) 266-8889
Audrey Jeung
TELEPHONE:
(650) 266-8891
DATE:
11/04/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
11
Document Has Been Signed on
11/05/2024 04:44 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
COMFORT HOME II
FACILITY NUMBER:
415600011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as hot water temperature tested at 133 degrees in client bathroom. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/06/2024
Plan of Correction
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2
3
4
Hot water temperature will be lowered and maintained between 105 and 120 degrees. Proof of correction to be sent to CCLD BY DUE DATE.
Section Cited
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as Lysol, Zep liquid cleaner and Bona floor cleaner are stored in unlocked cabinet in common bathroom and two containers of Zerex anti-freeze auto coolant, paint can, and multiple containers of cleaning products are observed on backyard patio.
This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/05/2024
Plan of Correction
1
2
3
4
Cleaners stored in bathroom were removed to inaccessible storage and backyard chemicals were relocated to locked storage shed in LPA's presence.
Deficiency corrected and cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
TELEPHONE:
(650) 266-8889
Audrey Jeung
TELEPHONE:
(650) 266-8891
DATE:
11/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2024
LIC809
(FAS) - (06/04)
Page:
2
of
11
Document Has Been Signed on
11/05/2024 04:44 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
COMFORT HOME II
FACILITY NUMBER:
415600011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on absence of current administrator certificates and confirmation from staff, the licensee did not comply with the section cited above, as there is no one currently who maintains a current RCFE administrator certificate. RCFE administrator certificates for Staff #1 and #2 expired in 2018 This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/06/2024
Plan of Correction
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2
3
4
Plan to obtain RCFE administrator certification will be sent to CCLD BY DUE DATE.
Section Cited
INCIDENTAL MEDICAL CARE 87465
(h)(6) A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on absence of Centrally Stored Medications Records, the licensee did not comply with the section cited above , as record of centrally stored medications is not maintained. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/06/2024
Plan of Correction
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2
3
4
Centrally Stored Medications Records shall be completed, maintained at facility, and copies sent to CCLD BY DUE DATE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
TELEPHONE:
(650) 266-8889
Audrey Jeung
TELEPHONE:
(650) 266-8891
DATE:
11/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2024
LIC809
(FAS) - (06/04)
Page:
3
of
11
Document Has Been Signed on
11/05/2024 04:44 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
COMFORT HOME II
FACILITY NUMBER:
415600011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on client records review, the licensee did not comply with the section cited above in 3 out of 5 client records reviewed, which poses an immediate health, safety or personal rights risk to persons in care.
- There are no client records maintained for clients #3, #4, #5.
POC Due Date:
11/06/2024
Plan of Correction
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2
3
4
Clients' records will be maintained on site. Proof of correction to be sent to CCLD BY DUE DATE.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
TELEPHONE:
(650) 266-8889
Audrey Jeung
TELEPHONE:
(650) 266-8891
DATE:
11/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2024
LIC809
(FAS) - (06/04)
Page:
4
of
11
Document Has Been Signed on
11/05/2024 04:44 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
COMFORT HOME II
FACILITY NUMBER:
415600011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
POSTURAL SUPPORTS
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on clients records review, the licensee did not comply with the section cited above in 5 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- All residents have half bed rails on their beds, and there are no MD orders on file
POC Due Date:
11/26/2024
Plan of Correction
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2
3
4
Written MD orders for half bed rails will be sent to CCLD BY DUE DATE for ALL residents.
Section Cited
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above, as backyard is strewn with items: metal shelving, suitcase, 7 large plastic storage boxes with lids, electric fireplace mantle, plastic sheeting, boxes of toys, 5-gallon water containers, bicycles, exercise equipment, plastic garbage containers. Backyard fence is missing several boards. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/26/2024
Plan of Correction
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2
3
4
Backyare will be cleared and backyard fence will be repaired. Proof of correction to be sent to CCLD BY DUE DATE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
TELEPHONE:
(650) 266-8889
Audrey Jeung
TELEPHONE:
(650) 266-8891
DATE:
11/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2024
LIC809
(FAS) - (06/04)
Page:
5
of
11
Document Has Been Signed on
11/05/2024 04:44 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
COMFORT HOME II
FACILITY NUMBER:
415600011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as side yard on east side is not easily accessible because barbecue grill, compressor tank, exercise bicycle and cabinet partially obstruct passageway to gate.
This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/26/2024
Plan of Correction
1
2
3
4
Side passageways will be cleared and free of obstructions. Proof of correction to be sent to CCLD BY DUE DATE.
Section Cited
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff records review, the licensee did not comply with the section cited above in 2 out of 5 records reviewed, as health screening and/or TB test results are not maintained for Staff #3 and #4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/26/2024
Plan of Correction
1
2
3
4
Current health screenings and/or TB test results for staff #3 and #4 will be sent to CCLD BY DUE DATE
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
TELEPHONE:
(650) 266-8889
Audrey Jeung
TELEPHONE:
(650) 266-8891
DATE:
11/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2024
LIC809
(FAS) - (06/04)
Page:
6
of
11
Document Has Been Signed on
11/05/2024 04:44 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
COMFORT HOME II
FACILITY NUMBER:
415600011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff records review, the licensee did not comply with the section cited above in 2 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no documentation that Staff #5 and #6 have received 4 hours of training on postural supports, restricted health conditions and hospice care, and 8 hours of dementia care training.
POC Due Date:
11/26/2024
Plan of Correction
1
2
3
4
Proof of training on postural supports, restricted health conditions, hospice care, and dementia care for staff #5 and #6 will be sent to CCLD BY DUE DATE
Section Cited
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff records review, the licensee did not comply with the section cited above in 2 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no evidence that Staff #5 and #6 have current first aid training.
POC Due Date:
11/26/2024
Plan of Correction
1
2
3
4
Proof of current 1st aid training for staff #5 and #6 will be sent to CCLD BY DUE DATE
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
TELEPHONE:
(650) 266-8889
Audrey Jeung
TELEPHONE:
(650) 266-8891
DATE:
11/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2024
LIC809
(FAS) - (06/04)
Page:
7
of
11
Document Has Been Signed on
11/05/2024 04:44 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
COMFORT HOME II
FACILITY NUMBER:
415600011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on client records review, the licensee did not comply with the section cited above in 3 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There are no appraisals on file for clients #3, #4, #5.
POC Due Date:
11/26/2024
Plan of Correction
1
2
3
4
Updated appraisals for clients #3, #4, #5 will be signed, dated, and copies sent to CCLD BY DUE DATE.
Section Cited
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on client records review, the licensee did not comply with the section cited above in 3 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There are no MD assessments maintained for clients #3, #4, #5.
POC Due Date:
11/26/2024
Plan of Correction
1
2
3
4
MD assessments and TB test results for clients #3, #4, #5 will be sent to CCLD BY DUE DATE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
TELEPHONE:
(650) 266-8889
Audrey Jeung
TELEPHONE:
(650) 266-8891
DATE:
11/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2024
LIC809
(FAS) - (06/04)
Page:
8
of
11
Document Has Been Signed on
11/05/2024 04:44 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
COMFORT HOME II
FACILITY NUMBER:
415600011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on client records review, the licensee did not comply with the section cited above in 4 out of 5 records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There are no admission agreements maintained for clients #3, #4, #5, and admission agreement for client #1 is not signed.
POC Due Date:
11/26/2024
Plan of Correction
1
2
3
4
Completed and signed admission agreements will be maintained for ALL residents. Copies of RATE page and SIGNATURE page will be sent to CCLD for clients #1, #3, #4, #5 BY DUE DATE.
Section Cited
Register of Residents
(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on client records review, the licensee did not comply with the section cited above, as roster of current residents is not maintained. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/26/2024
Plan of Correction
1
2
3
4
Register of current residents shall include the resident's name and ambulatory status as specified in Sections 87506(b)(1) and (b)(10); information on the resident's attending physician as specified in Section 87506(b)(7); information on the resident's responsible person as specified in Section 87506(b)(6).
Copy of resident roster will be sent to CCLD BY DUE DATE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
TELEPHONE:
(650) 266-8889
Audrey Jeung
TELEPHONE:
(650) 266-8891
DATE:
11/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2024
LIC809
(FAS) - (06/04)
Page:
9
of
11
Document Has Been Signed on
11/05/2024 04:44 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
COMFORT HOME II
FACILITY NUMBER:
415600011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on absence of documentation and confirmation by staff, the licensee did not comply with the section cited above, as there is no documentation of disaster drills available for review. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/26/2024
Plan of Correction
1
2
3
4
Documentation of disaster drills conducted will be sent to CCLD BY DUE DATE.
Section Cited
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on client records review, the licensee did not comply with the section cited above, as there is no documentation available to staff for 3 residents, in the event of an emergency. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/26/2024
Plan of Correction
1
2
3
4
(1) A resident roster with the date of birth for each resident.
(2) Anappraisal of resident needs and services plan for each resident.
(3) A resident medication list for residents with centrally stored medications.
(4) Contact information for the responsible party and physician for each resident.
Proof that the above information is available to staff at all times will be sent to CCLD BY DUE DATE
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
TELEPHONE:
(650) 266-8889
Audrey Jeung
TELEPHONE:
(650) 266-8891
DATE:
11/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2024
LIC809
(FAS) - (06/04)
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Document Has Been Signed on
11/05/2024 04:44 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
COMFORT HOME II
FACILITY NUMBER:
415600011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as there are no oxygen in use signs posted at entrance doors or bedroom doors for 3 residents who have oxygen in their rooms. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/26/2024
Plan of Correction
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2
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Oxygen in use signs will be posted outside of facility entrances and outside of bedroom doors. Proof of correction will be sent to CCLD BY DUE DATE.
Section Cited
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on client records review, the licensee did not comply with the section cited above, as client #5 is receiving hospice care, but there is no hospice care plan maintained. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/26/2024
Plan of Correction
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Hospice care plan for client #5 will be maintained and copy will be sent to CCLD BY DUE DATE.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
TELEPHONE:
(650) 266-8889
Audrey Jeung
TELEPHONE:
(650) 266-8891
DATE:
11/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/05/2024
LIC809
(FAS) - (06/04)
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