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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001829
Report Date: 07/25/2022
Date Signed: 07/26/2022 08:38:17 AM

Document Has Been Signed on 07/26/2022 08:38 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:KANNO'S COMFORT CAREFACILITY NUMBER:
507001829
ADMINISTRATOR:JANET KANNOFACILITY TYPE:
735
ADDRESS:3602 E. ORANGEBURGTELEPHONE:
(209) 526-8934
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Saul KaanoTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Arielle Pascua and Licensing Program Manager (LPM) Stephenie Doub, arrived at the facility on 07/05/2022 at 12:30pm to conduct an unannounced annual visit. LPA observed a sign for an active COVID case on the facility front door. LPA rang the doorbell and a caregiver answered the door and confirmed that there is an active COVID case at the time. LPA Pascua will return at another time to complete the annual visit.
Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua conducted an unannounced Required-1 Year visit on 07/25/2022. LPAs met with the Facility Designated Administrator, Saul Kanno and stated the purpose of today's visit. 2 staff members were present. Census was 6 residents.
A tour of this facility was conducted.
Fire extinguishers appeared to have been annually inspected on 02/04/2022.

A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet resident needs at this time.

A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

LPAs observed a locked centralized stored medication cabinet located in the hallway. Along with the administrator, the LPAs observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

The kitchen area was toured. LPAs observed a sufficient seven days of non-perishable foods as well as two days worth of perishable food supplies in the main kitchen. Additional perishable supplies were identified in an additional refrigerator in the back patio.

Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2022
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: KANNO'S COMFORT CARE
FACILITY NUMBER: 507001829
VISIT DATE: 07/25/2022
NARRATIVE
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The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.



Appeal rights were printed and a copy was given to the facility designated Administrator.

Exit Interview.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/26/2022 08:38 AM - It Cannot Be Edited


Created By: Arielle Pascua On 07/25/2022 at 11:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: KANNO'S COMFORT CARE
FACILITY NUMBER: 507001829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
8088(b)
(b) All window screens shall be in good repair and be free of insects, dirt, and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited since the window screens were not present and residents may not open their windows without pests entering the facility, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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Licensee agrees to purchase window screens and send the receipt and picture in to the LPA's email by 08/01/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022


LIC809 (FAS) - (06/04)
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