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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850323
Report Date: 04/20/2023
Date Signed: 04/20/2023 11:05:45 AM

Document Has Been Signed on 04/20/2023 11:05 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COMFORT ZONE CALFACILITY NUMBER:
195850323
ADMINISTRATOR:TAVITIAN, HRIPSIME RIPAFACILITY TYPE:
740
ADDRESS:13303 REEDLEY STREETTELEPHONE:
(310) 430-0075
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 6CENSUS: 1DATE:
04/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Hripsime TavitianTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20230309110540). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation.

During the complaint investigation of complaint # 29-AS-20230309110540, the following deficiency was observed: On 02/27/2023, Resident #1 (R1) suffered an unwitnessed fall in the middle of the night which resulted in R1 suffering from a subdermal hematoma and subarachnoid hemorrhage. Staff dialed 9-1-1 and called for an ambulance as R1 was observed on the floor with blood on their head. R1 was ultimately taken out of the facility and hospitalized due to the fall. Record review and interviews conducted revealed that neither incident was reported to Community Care Licensing (CCL) or the serious incident/injury report (LIC 624) was submitted to CCL within seven (7) days of occurrence as required by the California Code of Regulations.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit Interview. Citation issued. A copy of the report and appeal rights were issued to the Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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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Document Has Been Signed on 04/20/2023 11:05 AM - It Cannot Be Edited


Created By: Martha Arroyo On 04/20/2023 at 10:50 AM
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 ZONE CAL
FACILITY NUMBER: 195850323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited
CCR
87211(a)(1)(D)

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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety or health of any resident.

This requirement is not met as evidenced by:
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POC: The Licensee will submit a plan detailing how the facility will maintain in compliance of Regulation 87211 and submit to CCL by 04/24/2023.
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Based on interviews and documents reviewed, the licensee did not comply with the section cited above as the facility did not submit the unusual incent/injury report for R1 within 7 days of occurrence to CCL, which poses a potential health & safety risk to residents in care.
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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:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023


LIC809 (FAS) - (06/04)
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