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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801777
Report Date: 05/21/2021
Date Signed: 05/21/2021 01:20:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COMFORTS OF HOME SENIOR CARE, INC.FACILITY NUMBER:
425801777
ADMINISTRATOR:TRINA DELLINGERFACILITY TYPE:
740
ADDRESS:16 SAN DIMAS AVENUETELEPHONE:
(805) 451-5027
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 5DATE:
05/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Trina Dellinger, AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an onsite one-year infection control annual visit to the above-named facility. LPA met with Administrator Trina Dellinger.

Entrance interview conducted.

There are currently five (5) residents residing in the facility. The facility is home to non-ambulatory residents with a dementia diagnosis. Two residents are currently on hospice.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. Three first aid kits were observed to be complete.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. There are five (5) fire extinguishers with current fire inspections. There are three (3) smoke-carbon monoxide alarms in the hallway. The smoke-carbon monoxide alarms are two in one type alarms. Each are in good working order. Additionally, there is a smoke alarm in each bedroom, and a smoke alarm in the common living area. There are a total of 9 smoke/carbon monoxide alarms throughout the facility.
Snacks and beverages are available for Residents in the facility upon request. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Cleaning agents and the kitchen trash can are kept in a locked cabinet under the kitchen sink. Medications are kept in a locked centrally stored cabinet. Sharps are kept in a locked drawer in the kitchen.
The backyard has a covered patio with outdoor furniture, and a locked shed. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.
There is one private bedroom for staff behind the kitchen and laundry area.
Please continue 809-C, Pg 2.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.
FACILITY NUMBER: 425801777
VISIT DATE: 05/21/2021
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The living room and dining area are neat and clean. The facility maintains a comfortable room temperature measured at 12:05 pm. Hallways, bedroom doors and walls are in good repair.
The facility has five (5) bedrooms for a capacity of six residents. Bedroom #5 is a shared bedroom with two residents residing in the room. All of the bedrooms are furnished with lights and nightstand lamps to provide sufficient lighting.
There are two bathrooms in the facility available for use for all residents.
All persons associated with the facility have a criminal background clearance.

Exit interview conducted. No citations were issued. A copy of the report has been issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC809 (FAS) - (06/04)
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