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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600819
Report Date: 12/06/2022
Date Signed: 12/06/2022 01:20:37 PM

Document Has Been Signed on 12/06/2022 01:20 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:COMFORT CARE HOME, LLCFACILITY NUMBER:
075600819
ADMINISTRATOR:REY & MARY JANE VELASQUEZFACILITY TYPE:
740
ADDRESS:870 SAN SIMEON DRIVETELEPHONE:
(925) 680-4682
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: 6DATE:
12/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Leonora Maneja, AdministratorTIME COMPLETED:
01:29 PM
NARRATIVE
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While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20221031085430) on 12/06/2022, LPA observed that one of the staff members was not associated to the facility.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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
Document Has Been Signed on 12/06/2022 01:20 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 12/06/2022 at 12:36 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: COMFORT CARE HOME, LLC
FACILITY NUMBER: 075600819

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2022
Section Cited
CCR
87355(e)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement is not met as evidenced by:
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The facility will associate the staff by submitting LIC 9182, and copy of the individual's Driver's license to CCLD by POC date. The individual will leave the facility and not return until associated.

CCLDSCOaklandRO@dss.ca.gov
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Based on interviews & records reviews, Licensee did not comply with the regulation above, by not having a staff member associated to the facility.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
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