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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850303
Report Date: 05/22/2024
Date Signed: 05/29/2024 11:23:10 AM

Document Has Been Signed on 05/29/2024 11:23 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COMFORT PLACE LTD, THEFACILITY NUMBER:
195850303
ADMINISTRATOR/
DIRECTOR:		OLUWOLE, KEMIFACILITY TYPE:
740
ADDRESS:11905 RIVERSIDE DRIVETELEPHONE:
(213) 570-2025
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 6CENSUS: 5DATE:
05/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:27 AM
MET WITH:Omowunmi BalogunTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced at 9:00 AM for a Case Management – Annual Continuation inspection. The LPA met with facility supervisor Omowunmi Balogun and explained the reason for the visit.

During the Required 1-Year on 03/15/2024, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility compliance of Title 22 Regulations. Physical plant tour was conducted during the Annual visit. Today, 05/22/2024 a brief tour was conducted. No health and safety concerns were identified during today's tour. Facility has a sprinkler system in place, last inspection report was conducted on 12/08/2022 with an expiration date of 09/30/2024. Test result “Pass”.

RECORD REVIEW: Began at 10:12 AM, staff and resident records were reviewed for documents including, but not limited to; admission agreement, health screening, TB test result, resident physician's report, needs and service appraisal, and personal rights. Five (5) out of five (5) resident records reviewed were missing consent forms and need and service plan. During the visit, the supervisor was able to complete all five (5) needs and service plan without resident’s signatures. Supervisor agreed to submit all completed and signed forms to LPA once each resident signs it. LPA reviewed five (5) staff files for documents including but not limited to staff training records, fingerprint clearance, health screening and TB test result. Record review and interview conducted revealed Staff #1 (S1) was employed by the company in March of 2023. S1 is working for this facility at least 20 hrs. per week. LPA reviewed the facility guardian roster and discovered that S1 does have fingerprint background clearance but is not associated to this facility.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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Document Has Been Signed on 05/29/2024 11:23 AM - It Cannot Be Edited


Created By: Valeria Conway On 05/22/2024 at 01:42 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT PLACE LTD, THE
FACILITY NUMBER: 195850303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of five residents have prescription medication dispensing error which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee agreed to have and inhouse training with all staff and to complete a statement of understanding on how to document the missing medications on the centrally stored medications and destruction record indicated the quantity and start dates as indicated on the form and recheck all residents centrally stored medication and destruction record to make sure it is complete and accurate.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 11:23 AM - It Cannot Be Edited


Created By: Valeria Conway On 05/22/2024 at 01:55 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMFORT PLACE LTD, THE
FACILITY NUMBER: 195850303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355
(e) 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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as S1 was employed by the company in March of 2023. S1 is working for this facility at least 20 hrs. per week. LPA reviewed the facility guardian roster and discovered that S1 does have fingerprint background clearance but is not associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Licensee agrees to associate staff to facility using the Guardian website before POC due date. Conducting further investigation an Incomplete fingerprint submission letter from DSS was mail to S1 and Comfort Place. New POC is to have Licensee write a declaration stating that Licensee understand that Mr Samuel will not work in the facility or have contact with any residents until S1 is background cleared and associated to the facility.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMFORT PLACE LTD, THE
FACILITY NUMBER: 195850303
VISIT DATE: 05/22/2024
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Continued from LIC 809

MEDICATION REVIEW: LPA conducted a medication review for five (5) residents with the facility supervisor between 12:25PM and 1:28PM. LPA observed the following three (3) medication discrepancies were noted. For Resident #1 (R1) LPA observed five (5) pills of Levothyroxine, in a bottle labeled with quantity of 90 pills, with instructions to take 1 tablet orally daily, and with a start date on documentation as 04/01/2024. Resident #2 (R2) had four (4) extra pills of Aspirin in a bottle labeled with quantity of 30 pills, with instructions to take 1 tablet orally daily, and with a start date on documentation as 05/01/2024. Resident #3 (R3’s) pill count reflected three (3) extra pills of Spironolactone in a bottle labeled with quantity of 30 pills, with instructions to take 1 tablet orally daily, and with a start date on documentation as 05/01/2024 and an additional five (5) extra pills of Spironolactone in a bottle labeled with quantity of 30 pills, with instructions to take 1 tablet orally daily, and with a start date on documentation as 05/01/2024. Staff could not provide an explanation for the discrepancy.

EMERGENCY DISASTER PLAN and Quarterly Drills: During today's visit, LPA reviewed the facility's infection control plan, Emergency drills, and Emergency Disaster Plan. All facility's policies and procedures related are adequate. The facility's Emergency Disaster Plan is complete and updated annually. Emergency drills are conducted quarterly, with the last drill taking place on 03/16/2024. Staff checks smoke detectors monthly, last test was 05/04/2024.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 the following deficiencies were observed and cited. Refer to the following LIC 809-D pages for list of deficiencies. Civil penalty issued in the amount of $500. Failure to correct deficiencies may result in additional civil penalties.


Exit Interview Conducted. Report was reviewed with Supervisor, and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
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