195850303-2-24-2023-29-AS-AASO-CPCV2X-20230224150351

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850303
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:04:57 PM

Document Has Been Signed on 02/24/2023 03:04 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COMFORT PLACE LTD, THE		FACILITY NUMBER:	195850303
ADMINISTRATOR:	OLUWOLE, KEMI		FACILITY TYPE:	740
ADDRESS:	11905 RIVERSIDE DRIVE		TELEPHONE:	(213) 570-2025
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY: 14		CENSUS: 0	DATE:	02/24/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Wummy Balogun		TIME COMPLETED:	03:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Angel Ascencio conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Wummy Balogun. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is a one story facility. At 1:25 p.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for six (6) bedridden residents. The facility has six (6) private resident bedrooms. All resident rooms have direct exits to the outside. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are no staff rooms – awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. There are two (2) bathrooms in the hallway. One (1) is designated as a staff bathroom. The resident bathrooms has a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Resident and staff records will be stored in a filling cabinet which is currently located near the front desk. Medications will be centrally stored in a locked cabinet near the front desk. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT PLACE LTD, THE	FACILITY NUMBER: 195850303
	VISIT DATE: 02/24/2023

NARRATIVE

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Kitchen knives will be stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in the kitchen. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room. It is screened and there are no tools. There was no alarms on all exterior doors but will be placing before residents admission. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are four (4) fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date. Hot water was tested in each bathroom, which included the resident bathroom(s) and any common bathrooms, in addition to the kitchen. The laundry area is located in the backyard. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a hallway closet. Extra incontinence supplies are stored in hallway closet. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in common hallway. Other required postings are posted in the common hallway.

Continued on LIC 809 C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT PLACE LTD, THE	FACILITY NUMBER: 195850303
	VISIT DATE: 02/24/2023

NARRATIVE

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The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by gates at the north and south side passageways. The gate to the driveway is moved manually. There is a door with gate with a self-latching mechanism for persons to enter the front yard. There is a locked storage shed in the back yard. There no bodies of water on the premises at the present time.

Component III Orientation was done on 02/24/2023.

Pre-Licensing is complete and this facility has no deficiencies.

This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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