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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507001829
Report Date: 08/22/2024
Date Signed: 08/22/2024 11:47:07 AM

Document Has Been Signed on 08/22/2024 11:47 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KANNO'S COMFORT CAREFACILITY NUMBER:
507001829
ADMINISTRATOR/
DIRECTOR:		JANET KANNOFACILITY TYPE:
735
ADDRESS:3602 E ORANGEBURG AVENUETELEPHONE:
(209) 526-8934
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 6CENSUS: 6DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Janet Kanno TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 08/22/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Janet Kanno and explained the purpose of the visit. The purpose of this visit was to conduct an annual visit. There was one other staff member present, Shelly Vavra.
This facility is licensed to serve an retain residents who are 18 to 59 years of age. This facility is also vendorized by Valley Mountain Regional Center to serve and retain Level 2 residents at this time.
Current Census was 6. 2 out 6 residents were out on resident outings at this time. This facility was also observed to have been replacing their cracked tiles at the time of this visit.
LPA reviewed 3 resident files.3 out 3 resident files were current and up to date. LPA reviewed 4 staff files. 4 out 4 staff files were current and up to date. The administrator has a active certificate #7034606735 and expires on 11/20/2025.
A tour of this facility was conducted.
Fire extinguishers appeared to have been annually inspected by Jorgenson Fire Co. on 09/06/2023. 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.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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
FACILITY NUMBER: 507001829
VISIT DATE: 08/22/2024
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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

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies are being cited today in violation of California Code of Regulations.

An exit interview was held and a copy of this report was given to the facility at the end of this visit.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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