195850303-4-22-2025-29-AS-KLOZ-DG86U3-20250429210629

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850303
Report Date: 04/22/2025
Date Signed: 04/22/2025 02:02:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2025 and conducted by Evaluator Erica Mosley

COMPLAINT CONTROL NUMBER: 29-AS-20250410144752

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:	6	CENSUS: 6	DATE:	04/22/2025
		UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Omowunmi Balogun - Administrator Chika Anugwu - Staff		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not following resident's physician order for a special diet

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Erica Mosley and Quoc Huynh conducted an unannounced subsequent complaint visit to investigate the above allegation. The purpose of this visit is to deliver findings for the above allegation. Upon arrival at 9:51 a.m., LPA Mosley and Huynh were greeted by Staff who called the Administrator. The Administrator arrived during the visit. The LPAs met with Administrator, Omowunmi Balogun and explained the reason for the visit. The Administrator had to leave prior to deliver findings and designated staff Chika Anugwu to sign the report.

On 04/10/2025 the Department received a complaint regarding the following allegation Staff are not following resident's physician order for a special diet. On 04/10/2025 LPA Mosley conducted the initial 10-day complaint visit. Strating at 9:48 a.m., LPA conducted a brief physical plant tour to ensure there were no immediate health and safety concerns, conducted an in-person interview with the Administrator, conducted a file review and obtained copies of pertinent documents relevant to the investigation.
Report continued on LIC 9099-C PAGE 2...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 29-AS-20250410144752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/22/2025

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
26
27
28
29
30
31
32

(Page 2) Report continued from LIC 9099...

During today’s visit, starting at 9:51 a.m. LPAs conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. Starting at 9:59 a.m. LPAs conducted an in-person interview with one (1) staff, a telephonic interview with one (1) staff and R1’s California Department of Health Care Services Case worker (CDHCS CW), in person interview with Resident #1 (R1), inspected the kitchen and food service area, a file review and obtained copies of pertinent documents relevant to the investigation.

On the allegation Staff are not following resident's physician order for a special diet it is the concern of the reporting party (RP) that the facility is not providing accommodations for R1’s special diet. To investigate this complaint, LPAs conducted in person interviews with one (1) staff and the Administrator, telephonic interviews with one (1) staff and CDHCS CW, inspected the kitchen and food service area and reviewed documents relevant to the investigation. Interview with R1 revealed that the food provided at the facility is not to their liking and would prefer to have food that is aligned to their culture. R1 stated that the facility does not provide accommodations for the special diet. Interviews with staff revealed that the facility provides R1 with accommodations for a special diet however R1 refuses to accept the accommodations. Staff #1 (S1) revealed that they prepare the meals at the facility and always provide accommodations for R1’s special diet. R1 will refuse the food that goes along with the special diet and request substitutions that do not follow the special diet. Interview with Staff #2 (S2) revealed that the facility provides the proper accommodations for R1 however R1 refuses. S2 states that R1 has stated multiple times that the food that is provided is not to their liking. R1 would prefer to have food that is aligned to their culture however it is not aligned to the special diet. Interview with the Administrator revealed that R1 refuses meals that go along with the special diet. The facility provides accommodations to all meals for R1 however R1 refuses. Inspection of the kitchen and food service area revealed that the facility has information posted with food choices/ suggestions for R1’s special diet. Refrigerator and food pantry were inspected for special diet products.

Report continued on LIC 9099-C PAGE 3...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20250410144752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/22/2025

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
26
27
28
29
30
31
32

(Page 3) Report continued from LIC 9099C...

The facility had multiple items listed on the special diet food choices such as unsweetened almond milk, plain yogurt, brown rice, whole grain pasta, corn, bell peppers, cucumbers, lettuce, apples, grapes and unsweetened tea. Documents reviewed revealed that the facility has accommodations and substitutions on the menu. R1 has refused recommendations from the staff to follow the special diet on multiple occasions dating back to when R1 was first admitted. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff are not following resident's physician order for a special diet is deemed unsubstantiated at this time.

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

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3