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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486802064
Report Date: 04/29/2024
Date Signed: 04/29/2024 05:05:27 PM


Document Has Been Signed on 04/29/2024 05:05 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:COMFORT LIVING FOR SENIORS IIFACILITY NUMBER:
486802064
ADMINISTRATOR:SADDI, DONABELL W.FACILITY TYPE:
740
ADDRESS:685 PURPLE MARTIN DRIVETELEPHONE:
(707) 410-9706
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 6DATE:
04/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Donabell Saddi, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Stefanie Mutialu and Jill Nakagawa arrived unannounced to conduct an inspection of the facility and found 6 residents in care. There were 2 care staff on site. Licensee arrived 15 minutes later.

LPAs inspected the facility and found 5 of 6 residents socializing in the living room and watching television. The rooms were clean and had appropriate bedding. Kitchen was clean and had ample supply of perishable and nonperishable food, as required per Title 22. During inspection LPAs observed an unlocked shed with potential hazards inside, including pesticides, paint, sharp tools. Also, LPAs observed an unsecured can of disinfectant, over-the-counter medications and an inhaler during the inspection of bathrooms. LPAs provided facility with Regulation 87309(a) and 87705(f)(2).


Deficiency/ies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with facility Licensee, whose signature on this document confirms receipt.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
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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Document Has Been Signed on 04/29/2024 05:05 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: COMFORT LIVING FOR SENIORS II
FACILITY NUMBER: 486802064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2024
Section Cited
CCR
87705(f)(2)

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87705 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 was not met as evidence by:**


This requirement is not met as evidenced by:
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Licensee failed to ensure that toxin, medicationss and other items that could constitute a danger to the resident(s) were stored inaccessible to residents in care with dementia. Licensee immediately locked the items in designated cabinets. In addition, Licensee is to ensure medications and cleaning supplies are kept secured and submit a Proof of Corrections to CCLD by POC due date 4/30/24.
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Based on LPAs observation over-the counter drugs and inhalers were found unsecured which poses an immediate threat to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
04/29/2024
Section Cited
CCR87309(a)

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87309(a) STORAGE SPACE - Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement was not met as evidence by:** Based on observations LPAs found storage shed in backyard unlocked containing sharp tools, pesticides located in the backyard to be
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Licensee failed to ensure sharps, tools and toxic chemicals were kept secured and inaccessible to residents in care. Licensee agrees to purchase a new lock for shed door for staff and complete signage posted in the facility to ensure future compliance. Photos of signage and new lock submitted to CCL by POC due date 4/30/24.
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tools and chemicals accessible to residents. In addition, LPAs found 4 knives and 1 pair of large scissors located in drawer in kitchen unlocked and unsecured. This poses as an immediate health and safety risk to residents in care.
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024
LIC809 (FAS) - (06/04)
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