425801777-3-7-2023-29-AS-KKOS-CPQ3LU-20230307172120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801777
Report Date: 03/07/2023
Date Signed: 03/07/2023 05:22:15 PM

Document Has Been Signed on 03/07/2023 05:22 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COMFORTS OF HOME SENIOR CARE, INC.		FACILITY NUMBER:	425801777
ADMINISTRATOR:	TRINA DELLINGER		FACILITY TYPE:	740
ADDRESS:	16 SAN DIMAS AVENUE		TELEPHONE:	(805) 451-5027
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	6	CENSUS: 5	DATE:	03/07/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Gary Gleissner, Licensee		TIME COMPLETED:	05:45 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Rachael DeLeon and Kristin Kontilis conducted a Case Management visit to address deficiencies noted during a required Annual Inspection visit conducted on 3/7/2023. LPAs met with Gary Gleissner, Licensee and explained the purpose of the visit.
At the time of the visit, LPAs reviewed residents’ records and conducted interviews with staff and residents. Interviews conducted revealed that Resident 1 (R1) sustained a fall in October 2022; facility administrator called 9-1-1 and R1 was transferred to the hospital. Interviews further conducted revealed R1 remained in the hospital and was eventually transferred to a skilled nursing facility then returned to the facility after several weeks. R1 was placed on hospice on or about 12/9/2022. R1 passed away at the facility on or about 1/29/2023.
Upon record review and interviews conducted, LPAs determined no hospice notifications have been received by CCL although facility has a hospice waiver for two (2) residents. Records reviewed and interviews conducted revealed no Serious Illness/Serious Injury (LIC624) reports have been received by CCL since 3/5/2021. Records reviewed revealed no death reports (LIC624A) has been received by CCL reporting R1’s death and/or other residents’ deaths since 3/5/2021.
LPAs counseled Staff 1 (S1)/Facility Designee on the importance of following the requirements in California Code of Regulations (CCR) 87632 Hospice Care Waiver and 87211 Reporting Requirements in their entirety to ensure adherence to the regulations.

Pursuant to Title 22, Division 6, Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC809-D).

Exit interview conducted. Deficiencies cited. Copy of report and Appeal Rights issued at the time of the visit.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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 03/07/2023 05:22 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/14/2023 Section Cited	1 2 3 4 5 6 7	87632(d)(2) Hospice Care Waiver: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.	1 2 3 4 5 6 7	Licensee agrees to conduct training with all staff responsible for submitting hospice notification. Training records will show full names of attendees, date of training, and person conducting training with first and last names in print and signature.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above as CCL has not received hospice notifications for residents placed on hospice which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 03/14/2023 Section Cited	1 2 3 4 5 6 7	87211(A)(1) Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below… This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to conduct training with all staff responsible for submitting Serious Illness/Serious Injury and/or Death Reports to CCLD. Training records will show full names of attendees, date of training, and person conducting training in print and signature.
	8 9 10 11 12 13 14	Based on records review, the licensee did not comply with the section cited above as CCL has not received Serious Illness/Serious Injury Reports and/or Death Reports since 3/5/2021 which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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