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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206741
Report Date: 04/21/2022
Date Signed: 04/21/2022 01:14:23 PM

Document Has Been Signed on 04/21/2022 01:14 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:COMFORT CARE HOME IVFACILITY NUMBER:
157206741
ADMINISTRATOR:DHILLON, AMARDEEP (AMY)FACILITY TYPE:
740
ADDRESS:4917 AU CHOCOLAT DRTELEPHONE:
(661) 204-4455
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 4DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Administrator, Amy DhillonTIME COMPLETED:
01:24 PM
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On 04/21/2022, Licensing Program Analyst (LPA) arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA was granted entry to the facility by Caregiver, Tina Wonderly who contacted Administrator, Amardeep Dhillon. Administrator arrived a short time later. There are 4 residents present during today's inspection.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were not observed by the bathroom sinks. 2 bedrooms are single occupant and 2 bedrooms double occupant. In the shared bedroom, LPA observed the beds to be at least 6 feet apart and 3 feet apart with head to toe orientation.

LPA checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. LPA observed a foul odor in the pantry from a bag of onions that had sprouted. The onions had attracted several gnats which were observed in the facility pantry. Administrator had the box of onions removed. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. LPA observed 2 out of 4 residents did not have an Admission agreement with the facility.

LPA is requesting the following documents be submitted to the Fresno CCL office by 05/05/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond

CONTINUED TO LIC809C

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: COMFORT CARE HOME IV
FACILITY NUMBER: 157206741
VISIT DATE: 04/21/2022
NARRATIVE
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Based on observation a deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview was conducted and a Plan of Correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, whose signature on this form confirms receiving this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2022 01:14 PM - It Cannot Be Edited


Created By: Alexandria Walton On 04/21/2022 at 12:53 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: COMFORT CARE HOME IV
FACILITY NUMBER: 157206741

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555
87555 General Food Service Requirements: (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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 above when gnats were observed to be in the food pantry due to the foul odor of onions that had sprouted,which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2022
Plan of Correction
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Licensee immediately removed the box of onions that attracted the gnats. Licensee agreed to train staff on the requirements of section 87555 General Food Service Requirlements and submit a copy of training topics and attendance to the Fresno CCL office by 05/23/2022.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


LIC809 (FAS) - (06/04)
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