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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801777
Report Date: 04/03/2024
Date Signed: 04/03/2024 12:13:20 PM


Document Has Been Signed on 04/03/2024 12:13 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 DELLINGERFACILITY TYPE:
740
ADDRESS:16 SAN DIMAS AVENUETELEPHONE:
(805) 451-5027
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY:6CENSUS: 5DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Trina Dellinger, AdministratorTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection to the above-named facility.
LPA was greeted by Staff 1 (S1). LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis. There are no residents on hospice at this time.
Entrance interview conducted:
At the time of the arrival, there were two (2) staff on duty and five (5) residents in care. LPA met with Administrator Trina Dellinger throughout the inspection.
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 facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition.
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. The living room and dining area are neat and clean.
The facility has five (5) bedrooms for a capacity of six residents. Bedroom #5 is a shared bedroom with two residents. 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 to all residents.
At approximately 11:20 AM, LPA observed Bedroom #4 has a foul odor. Advisory Notes - Technical Assistance issued.
There is one private bedroom for staff behind the kitchen and laundry area. The facility maintains a comfortable room temperature.

Please continue to 809-C, Pg 2.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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: 04/03/2024
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 LPA determined there is a sufficient amount of food consisting of two (2) days of perishables and seven (7) days of non-perishables. Snacks and beverages are available for Residents upon request.
The backyard has a covered patio with outdoor furniture and a locked shed. The front yard and backyard have seating areas, potted plants, and paved walkways conducive for outdoor visitations. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.
Residents records were reviewed for Physician’s reports, health screenings, pre-appraisals, re-appraisals, reporting requirements, and centrally stored medications.

Due to time restraints, LPA will return at a later date to continue the inspection.

Exit interview conducted. Advisory Notes - Technical Assistance issued. Copy of report issued at the time of the visit.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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