195850323-1-30-2023-29-AS-EPEI-CNL3H9-20230130171533

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850323
Report Date: 01/30/2023
Date Signed: 01/30/2023 05:16:06 PM

Document Has Been Signed on 01/30/2023 05:16 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 ZONE CAL		FACILITY NUMBER:	195850323
ADMINISTRATOR:	TAVITIAN, HRIPSIME RIPA		FACILITY TYPE:	740
ADDRESS:	13303 REEDLEY STREET		TELEPHONE:	(310) 430-0075
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY: 6		CENSUS: 4	DATE:	01/30/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:44 PM
MET WITH:	Hripsime Tavitian		TIME COMPLETED:	05:30 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) Emily Peraldi conducted a pre-licensing visit to the above noted facility. At 12:44 p.m., the LPA met with applicants . This a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is one story. At 1:10 p.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents and, one (1) of bedridden resident. The facility has four (4) resident bedrooms, all rooms are shared bedrooms except for Room #2 and Room #3. Resident bedroom #1 has a direct exit to the outside. Bedridden resident is allowed in resident bedroom #1. All resident rooms have beds, nightstands, lamps, chests of drawers, 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 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. Room # 5/ staff room is a designated staff room. All rooms were free of odors. All window screens were clean and maintained in good repair. There is an office area located near the dining area. There are cameras in the common areas. There are two (2) bathrooms in the facility. Resident bedroom #4 has a bathroom inside. The resident bathrooms have 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 not within the range of 105F and 120F. At 1:16 p.m., the kitchen hot water temperature measured at 125.0F. At 1:51 p.m., the bathroom hot water temperatures measured between 129.4F. Resident and staff records are stored in a locked cabinet which is currently located near the dining area. Medications are centrally stored in a locked cabinet near the dining area. The first aid supplies were incomplete.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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 ZONE CAL	FACILITY NUMBER: 195850323
	VISIT DATE: 01/30/2023

NARRATIVE

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Kitchen knives are stored in a locked drawer in the kitchen. 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 cabinet located in the locked laundry hallway. 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. There was sufficient space to accommodate both indoor and outdoor activities. Night lights will be maintained in hallways and passageways to nonprivate bathrooms. All ramps were not secured and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. At 1:22 p.m., the LPA observed a hole in the back-patio ramp. Alarms on all exterior doors were engaged at the time of visit and not functional. Room #1 auditory device was not functional. 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 did not have emergency food and water supplies. 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. At 1:47 p.m., the smoke detector and carbon monoxide detectors were tested and functioned properly. The facility has a central entry point for symptom screening and temperature checks for staff and visitors. There is hand sanitizer available throughout the facility.

There is a fire extinguisher near the kitchen area. It was fully charged and purchased on 03/22/2022. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in the laundry closet. Extra incontinence supplies are stored in the laundry closet and in the garage. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout the facility. The emergency telephone numbers will be posted near the entrance of the facility. Other required postings will be posted near the entrance of the facility.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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 ZONE CAL	FACILITY NUMBER: 195850323
	VISIT DATE: 01/30/2023

NARRATIVE

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The exterior passageways were clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. There is a gate with a knob mechanism that is not locked at the side of the house designated for an emergency exit. There are bodies of water on the premises at the present time. The swimming pool is fenced and locked. The garage is not accessible from the house; the garage door was locked.

The following items must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to the LPA so that your application may be completed.
- The facility needs to be clean and in good repair. The back patio ramp has a small hole. Room #3’s door to the restroom needs to be fixed. Room #2’s door needs to be fixed.
- The hot water temperature for both the kitchen and bathrooms needs to read within the allowable range of 105*F to 120*F.
- A complete first aid kit.
- The facility needs to have emergency food and water.
- Required postings need to be posted.
- 30-day supply of Personal Protection Equipment (PPE).
- Lid for bathroom trash can.

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: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

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