195850303-4-10-2025-29-AS-EMOY-DFLV3J-20250410160451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850303
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:05:02 PM

Document Has Been Signed on 04/10/2025 04:05 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COMFORT PLACE LTD, THE		FACILITY NUMBER:	195850303
ADMINISTRATOR/ DIRECTOR:	OLUWOLE, KEMI		FACILITY TYPE:	740
ADDRESS:	11905 RIVERSIDE DRIVE		TELEPHONE:	(213) 570-2025
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY: 6		CENSUS: 6	DATE:	04/10/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Omowunmi Balogun - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:11 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) Erica Mosley conducted a Case Management - Incident visit to follow up on a self-reported incident which took place on 04/03/2025. At 9:45 a.m. LPA Mosley was greeted by staff and Administrator, Omowunmi Balogun and the reason for the visit was explained. Entrance interview. On 04/02/2025, it was reported that Resident 1 (R1) made the accusation to the Administrator that there are no staff at nighttime, R1 had an altercation with Staff #1 (S1) where S1 attacked R1 and staff serve the same meal every day. During today's visit, from 9:45 a.m. LPA conducted a physical plant tour to ensure there were no immediate health and safety concerns. On 04/09/2024 from 12:46p.m.- 2:20p.m. LPA conducted a brief physical plant tour, conducted in person interviews with the Administrator, two (2) staff including S1, three (3) residents including R1, a file review and obtained copies of pertinent documents relevant to the incident. On the accusation that there are no staff at nighttime the LPA conducted interviews with the Administrator, two (2) staff, and three (3) residents including R1. Interviews with the staff revealed that they always have staff at night. They have two (2) live in staff who are readily available. Staff state they regularly have two (2) staff scheduled throughout the day and night. There are always staff available. They have never left the residents alone at night. Interviews with residents revealed that they always have staff at night. They have not been left alone without any staff. Interview with R1 revealed that one morning, day unknown at 5:00 a.m. staff took longer than normal to assist and was upset that the staff took longer than usual. R1 stated that they do have staff at night. R1 stated that S2 is available at night and helps regularly. R1 stated that they were upset with the staff and told the Administrator that no one was here. Report continued on LIC 809-C PAGE 2...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/10/2025

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(PAGE 2) REPORT CONTINUED FROM LIC 809...

Interview with the Administrator revealed that they have staff regularly scheduled and always have staff at night. R1’s California Department of Health Care Services (DHCS) Case worker (CW) was made aware of the accusation and came the next day to speak to R1 and gave the facility interventions for R1.

On the accusation R1 had an altercation with S1 where S1 attacked R1 the LPA conducted interviews with the Administrator, two (2) staff including S1, and three (3) residents including R1. Interviews with that staff revealed that they are unaware of any altercation with R1 and S1. S1 did not attack R1. S2 stated that there has not been any altercation with R1 and S1.S1 did not attack R1. S2 stated that R1 was upset with S1 for telling R1 to not open the door to strangers and that the Staff would open the door for their safety. R1 then proceeded to yell and use profanity towards S1 and stormed off. Interview with S1 revealed that S1 did not get into any altercation with R1. R1 was upset with S1 for telling R1 to not open the door to strangers. Interview with R1 revealed that they did not have any physical altercation with S1. S1 did not push or put their hands on R1. S1 did not attack R1. Interview with the Administrator revealed since the accusation an Inservice training was conducted on 04/04/2025 with all the staff on Abuse, Abuse reporting procedures, Resident Rights, and Effective communication.

On the accusation staff serve the same meal every day the LPA conducted interviews with the Administrator, two (2) staff, and three (3) residents including R1. Interview with staff revealed that they do not serve the same meal everyday and have photo proof of what is served daily. Staff follow a monthly menu that cover all nutritional guidelines. Interview with residents revealed that the same meal is not served every day, and the food is of good quality. Interview with R1 revealed that the facility does not serve the same meal everyday but that the food is not to their liking. R1 would prefer food that is culturally aligned with their culture. R1 states that the food is okay and good quality but not to their liking. Interview with the Administrator revealed that the facility has mad efforts to bring in more of R1’s culture into the food they provide.

No deficiencies were observed during today’s inspection. Exit interview conducted. Report was reviewed and a copy was provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC809 (FAS) - (06/04)

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