Community Care Licensing

Document Has Been Signed on 03/18/2023 10:09 AM - It Cannot Be Edited

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:	03/17/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Gary Gleissner, Back to Administrator		TIME COMPLETED:	04:20 PM

SUPERVISORS NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type A

Section Cited

HSC

1569.618(c)(3)

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have records to review which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2023
	Plan of Correction
1 2 3 4	Administrator will send 4 staff CPR card/training to CCL.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator will provide Health Screening with TB results on all 4 staff to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

CCR

87412(f)

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above the Facility did not have personnel records to review at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Admnistrator agreed to produce all records/files for Facility at the facility.

Type B

Section Cited

CCR

87412(g)

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation record review, the licensee did not comply with the section cited above in 4 out of 4 staff records were not being maintained at the facility for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Admiinistrator agreed to provide CCL with all 4 personnel records.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

CCR

87411(d)

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 4 of 4 staff records were not avaibale for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide annual trianing records to CCL.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on Record review the licensee did not comply with the section cited above in 4 of 4 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all traning initial and annual to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

HSC

1569.625(b)(2)

(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 observation and record review, the licensee did not comply with the section cited above in 4 out of 4 Staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all initail and annual dementia training for all staff to CCL.

Type B

Section Cited

HSC

1569.625(c)(8)

(c) The training shall include, but not be limited to, all of the following: (8) The special needs of persons with Alzheimer’s disease and dementia, including nonpharmacologic, person-centered approaches to dementia care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have the required dementia training records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all trianing records on dementia to CCL for a 4 staff.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

CCR

87411(c)(1)

(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 observation and record review, the licensee did not comply with the section cited above in 4 out of 4 Staff did not have records of 1st aid traning or cards which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all 4 staff 1st aid trianing cards to CCL.

Type B

Section Cited

HSC

1569.626(a)(1)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have records to review for staff trianing which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all staff trianing records to met this requirement and send to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

HSC

1569.626(a)(2)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have traning records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all staff training records to met this requirement to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

HSC

1569.696(a)

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have trianing records to review to met this requirement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to send all 4 staff trianing records to CCL.

Type B

Section Cited

HSC

1569.696(a)(1)

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff trianing records were not avaiable to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to send all 4 staff trianing records to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

HSC

1569.696(a)(2)

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (2) Four hours of training thereafter of in-service training per year on the subject of serving those residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide records to CCL.

Type B

Section Cited

HSC

1569.69(a)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review], the licensee did not comply with the section cited above in 4 out of 4 staff did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Admnistrator agreed to provide all staff training records to met this requirement to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

HSC

1569.69(a)(2)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide staff training records to met this requirment for 4 staff and provide to CCL.

Type B

Section Cited

HSC

1569.69(a)(3)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (3) An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. The training and instruction described in this subdivision shall be completed, in their entirety, within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have trianing records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all 4 staff training records to met this requirement to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

HSC

1569.267(d)

(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have reocrds to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Admnistrator agreed to provide records to CCL.

Type B

Section Cited

CCR

87462

The facility shall obtain sufficient information about each person's likes and dislikes and interests and activities, to determine if the living arrangements in the facility will be satisfactory, and to suggest the program of activities in which the individual may wish to participate. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 resident did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to proivde records to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

HSC

1569.7

Residential care facilities for the elderly that serve residents with Alzheimer’s disease and other forms of major neurocognitive disorder should include information on sundowning as part of the training for direct care staff, and should include in the plan of operation a brief narrative description explaining activities available for residents to decrease the effects of sundowning, including, but not limited to, increasing outdoor activities in appropriate weather conditions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Adminsitrator agreed to provide records to CCL.

Type B

Section Cited

CCR

87465(b)

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 reisdents did not have LIC 602A to review for this requirement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide records to met this requirement to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

CCR

87465(c)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents did not have these records available to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide records to met this regualtion adn provide to CCL.

Type B

Section Cited

CCR

87465(c)(3)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents did not have these records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Adminsitrator agreed to provide records to met this regualtion to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

CCR

87465(d)

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents did not have records to reviwew for this requirement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all residents records to CCL.

Type B

Section Cited

CCR

87465(d)(1)

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all 5 residents records to CCL to met this regulation.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

CCR

87465(d)(2)

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 of 5 reisdents did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide records of all 5 residents to met this regualtion to CCL.

Type B

Section Cited

CCR

87465(d)(3)

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all 5 reisdents records to met this regualation to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

HSC

1569.695(b)

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all staff records to met this regulation to CCL.

Type B

Section Cited

HSC

1569.695(c)

(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 record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have trianing records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all staff trianing records to met this regualtion to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

CCR

87606(f)(3)

(f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all staff traning to met this regualtion to CCL.

Type B

Section Cited

CCR

87705(c)(3)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all staff traning to met this regualtion to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

CCR

87705(c)(3)(A)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all 4 staff training records to met this regualtion to CCL.

Type B

Section Cited

CCR

87705(c)(5)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all 5 residents records to met this regulation to CCL.

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023

Link to Parent Document Below:

FACILITY NAME: COMFORTS OF HOME SENIOR CARE, INC.	FACILITY NUMBER: 425801777
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Type B

Section Cited

CCR

87705(c)(5)(A)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents did not have records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all residents records to met this regualtion to CCL.

Type B

Section Cited

CCR

87705(c)(6)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents did not habe records to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to provide all residents records to met this regulation to CCL

SUPERVISOR'S NAME: Kelly Burley LICENSING EVALUATOR NAME: Rachael De Leon LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023