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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 587004202
Report Date: 01/17/2024
Date Signed: 01/17/2024 03:25:43 PM


Document Has Been Signed on 01/17/2024 03:25 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:COMFORT CARE ELDERLY HOMEFACILITY NUMBER:
587004202
ADMINISTRATOR:USVAT, SIMONAFACILITY TYPE:
740
ADDRESS:4205 MARY AVENUETELEPHONE:
(530) 749-9543
CITY:OLIVEHURSTSTATE: CAZIP CODE:
95961
CAPACITY:6CENSUS: 1DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Simona UsvatTIME COMPLETED:
04:00 PM
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On 1/17/2024 LPA Tryon visited the facility to do an annual visit. LPA met with licensee Simona Usvat.
The facility currently has one resident.
LPA toured the house with Mrs. Usvat including common areas, kitchen, food supplies, storage, bedrooms, bathrooms, hallways, laundry, outside areas.
The home is clean and well-furnished, appropriate bedroom furniture, etc.
Food supplies appear appropriate to meet the requirement of 2 days perishable and 7 days non-perishable supplies. Cleaners and other potentially harmful substances are secured. Sharp knives are locked. Refrigerator and freezer are kept at appropriate temperatures.
Smoke and carbon monoxide detectors installed and functioning.

LPA reviewed the CARE Tool with licensee.

LPA reviewed one of one resident file, and two of two staff files. Files appear to have appropriate documentation.

LPA interviewed one of one resident and one staff.

At this time the facility appears to be in substantial compliance. No deficiencies were cited at this visit.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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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