425801777-3-7-2023-29-AS-RDLN-CPQ3MS-20230307172250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801777
Report Date: 03/07/2023
Date Signed: 03/07/2023 05:24:05 PM

Document Has Been Signed on 03/07/2023 05:24 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:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Gary Gleissner, Back to Administrator		TIME COMPLETED:	05:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst's (LPA's) De Leon and Kontilis conducted a 1 year Annual visit to the facility above. LPA's met with Gary Gleissner, Licensee and explained the purpose of the visit. LPA's took a physical plant tour of the facility with Licensee. The Facility has submitted a mitigation plan and Emergency Disaster Plan to the department. The facility has not submitted an infection control plan to the department. The facility has a central entry point to sign in and symptom screen. Routine symptom screening is being conducted on all client in care and anyone showing any signs or symptoms is isolated and tested. Signs are posted at entrance and in the common areas of the facility regarding Covid-19. Hand Sanitizer is available at entry, every room, and the facility has 5 resident bedrooms and 2 resident rest-rooms with plenty of soap, paper towels, toilet paper, and hand washing signs. Trash bins have covers. Facility has 30+ days of PPE supplies. Facility staff wear masks at the facility and when on outings with clients. Facility staff will wear full PPE with N95 masks with face shields when dealing with any pending or confirmed cases of Covid-19. Facility will keep track of staff vaccinations. Facility staff have non-punitive sick leave policies and sick staff are requested to stay home and not report to work if they are ill. Facility has developed policies for Covid-19 precautions. PPE supplies are stored in storage areas accessible to staff working. Facility audits all supplies and replenishes when low. Administrator has a plan in place for back-up staffing when and if needed. All residents in care have the right to reject medical services. The facility keeps staff on duty who is trained and competent to handle and deal with emergency personnel. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
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)

Page: 1 of 30

Document Has Been Signed on 03/18/2023 10:10 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/17/2023 08:32 AM

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above tools and cleaners were all over on the back patio which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/08/2023
	Plan of Correction
1 2 3 4	Administrator agreed to clean up and lock up all dangerous equipment and supplies. Send pictures of back patio and side of house with alll items cleaned up and locked or inaccessible to residents in care.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above the facility has broken locks on medication cupboards and cleaning products around the inside of the facility accesible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/08/2023
	Plan of Correction
1 2 3 4	Administrator agreed to fix locks and store and lock all over the counter medications and cleaning products. Take pictures and send to CCL.

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: Rachael De Leon	TELEPHONE: (805) 450-0262
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)

Page: 2 of 30

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: 03/07/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The facility has an emergency plan which was not posted. Residents records were reviewed and all 5 residents in care are missing required forms. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Smoke and carbon monoxide detectors are present in the facility they are dual and hard wired. The facility did not have self closing and self latching gates as required by regulation. The kitchen oven, stove, and grease around the area needs to be cleaned. The showers do not have non slip mats. Cleaning products were not locked and some were left in areas accessible to residents. LPA Kontilis tested water in resident rest-rooms temperature was 117.5 F. Fire extinguishers were charged but had not been inspected since 11/20/2019 or none of them had a receipt attached for proof of purchase within 1 year.

LPA's will return at a later date to complete the annual inspection to review remaining resident files, staff files, training records and to conduct interviews as well as follow up on technical violations issued on today's visit.

Exit interview completed, technical violations issued and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
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

LIC809 (FAS) - (06/04)

Page: 30 of 30