502700654-8-18-2025-27-AS-ELIM-DKNQYE-20250818123501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502700654
Report Date: 08/18/2025
Date Signed: 08/18/2025 12:35:19 PM

Document Has Been Signed on 08/18/2025 12:35 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	KANNO'S COMFORT CARE 2		FACILITY NUMBER:	502700654
ADMINISTRATOR/ DIRECTOR:	KANNO, JANET		FACILITY TYPE:	735
ADDRESS:	1113 GRAND PRIX DR		TELEPHONE:	(209) 532-2260
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 4		CENSUS:	DATE:	08/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Janet Kanno, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 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	At 9:45 AM on 8/18/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by the house manager. The LPA identified herself, explained the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). The DFA arrived at the facility at 10:15 AM and an interview followed. The DFA and house manager accompanied the LPA on a tour of the facility. This facility is licensed to serve four ambulatory residents. The facility is a three bedroom, 2 bathroom house located in a residential area. The census was four consumers, although none were home at the time of this inspection. There was staff on duty. The LPA toured the inside of the house, including the bedrooms, bathrooms, kitchen, dining room, living room, garage, and laundry room. The entire house was clean, odor-free, and pest-free. The windows and window screens were in good repair. The required documents were posted near the front door and in the living room. The LPA inspected two smoke detectors, a carbon monoxide detector, and two fire extinguishers. The smoke detectors were in the bedroom hallway and kitchen. Staff tested the smoke detectors and both sounded an alarm. Staff tested the carbon monoxide detector in the kitchen and it sounded an alarm. Both fire extinguishers were last serviced on 9/9/2025 by Jorgensen; one is located in the bedroom hallway and one is in the kitchen. The LPA observed documentation of monthly disaster drills. The LPA Lindstrom that the thermostat was set at 76 degrees Fahrenheit. (cotinued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KANNO'S COMFORT CARE 2	FACILITY NUMBER: 502700654
	VISIT DATE: 08/18/2025

NARRATIVE

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Each bedroom contained the required furniture, including bed, bedside table, lamp, dresser, and chair. The bedrooms and their closets were clean, organized, and odor-free. One bedroom contained a full bathroom. A second bathroom was located in the bedroom hallway. Both bathrooms were clean and odor-free. The LPA measured the water temperature at a bathroom sink; the temperature of the water was 119 degrees Fahrenheit.

The LPA toured the kitchen. The kitchen was clean, the appliances were operable, and the tras hcan had a lid on it. There was a seven-day non-perishable and two-day perishable supply of food located in the kitchen refrigerator-freezer and cabinets. Sharp objects were kept locked in a lower kitchen drawer.

The LPA toured the dining room and living room. The LPA observed two couches, a recliner, and a TV in the living room. The connected dining room and kitchen each contained a dining table and chairs. There was a shelving unit in the dining room that contained activity items, including games and puzzles. There was artwork on the walls and large windows that let in natural light. The LPA observed extra linens in the entryway closet.

The LPA toured the garage and laundry room. The garage contained stored facility items and is inaccessible to consumers. The laundry contained the washer and dryer and a locked cabinet with chemical and toxic supplies.

The LPA toured the back yard, which was enclosed by a wooden fence. A section of the fence was being repaired; a chain link fence blocked this section of the fence. The LPA observed a table, chairs, and shade umbrella in the back yard. The concrete patio and walkways were free of obstruction.

(Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KANNO'S COMFORT CARE 2	FACILITY NUMBER: 502700654
	VISIT DATE: 08/18/2025

NARRATIVE

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The LPA inspected the central medication storage area. Residents’ medication was kept in a locked closet in the bedroom hallway. The LPA observed the paper-based medication administration record (MAR), which was complete and up-to-date. The LPA compared the MAR and medications for one resident; the two matched. Each resident's medication was stored in a separate storage unit and all medication was in its original containers. There was a first aid kit in the medication cabinet that contained all the required items.

The LPA reviewed records for two residents and two staff and found the records to be complete. Both staff had criminal background clearances and current first aid/CPR certifications. The Administrator’s certificate was valid (#7034606735) and expires 11/20/2025.The LPA inspection the P & I records and compared it to the conumer cash for one resident and both matched.

The LPA requested that updated copies of the following documents be submitted to Licensing by 8/29/2025 at ellen.lindstrom@dss.ca.gov.

(1) LIC 308 Designation of Facility Responsibility
(2) Copy of a current Administrator Certificate
(3) LIC 610D Emergency Disaster Plan
(4) Proof of Liability Insurance
(5) LIC 500 Personnel Report
(6) LIC 309 Administrative Organization

As a result of this inspection, no deficiencies were cited. The facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6.

An exit interview was conducted with the Licensee, to whom a copy of this LIC809 report was provided. Their signature below confirms receipt of this document.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2025

LIC809 (FAS) - (06/04)

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