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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603154
Report Date: 08/25/2021
Date Signed: 08/25/2021 11:56:51 AM

Document Has Been Signed on 08/25/2021 11:56 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:COMFORT CARE HOMEFACILITY NUMBER:
198603154
ADMINISTRATOR:NORA, PETERFACILITY TYPE:
740
ADDRESS:13548 REVA PLACETELEPHONE:
(714) 322-6480
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 6CENSUS: 5DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Euphrosyne DimaanoTIME COMPLETED:
12:00 PM
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On 8/25/2021 at 9:30 a.m. Licensing Program Analysts (LPAs) Nina Galarza and Nune Margaryan arrived at the facility to conduct an unannounced annual visit. LPAs met with Roel Franco and later met with administrator, Euphrosyne Dimaano and discussed the purpose of the visit. LPAs observed COVID informational and symptom signs in the front of the facility and through out the facility. LPAs were screened for COVID symptoms and temperature check at arrival.

This facility is located in a residential neighborhood, single story house with an attached two car garage with a iron door for access to the entrance, and contains (5) bedroom(s), (2) bathrooms, living room, dining room, office area, kitchen, . Bedroom #1 is designated as private for non-ambulatory resident, Bedroom #2 is designated as private for non-ambulatory resident, Bedroom #3 is designated as semi private for non-ambulatory/bedridden resident, Bedroom #4 is designated as private for non-ambulatory resident, Bedroom #5 is designated as private for non-ambulatory resident. All bedrooms contain the required furniture, lighting and storage space, continence supplies in the closets, free of obstructions or hazards and was observed to be clean and sanitary throughout the residence. Beds have the required linen; pillowcase, sheets, mattress pad/cover, blanket and bedspreads. Adequate supply of linen stored in hall cabinet with additional continence supplies, towels and blankets.
Medications were located in the hallway storage closet locked and inaccessible to the residents.
There are (4) emergency exits with delayed egress on the front door, door leading to the back yard and door in bedroom #3 and bedroom #5. There are no locks or bars included on the windows. The outdoor fence does not have any locking mechanism.
The front yard contains a driveway to the two garage, an iron door that leads to the front entrance. The sliding glass door, with a ramp to access the backyard contains a large covered patio with a shaded area with accessible seating available for resident use with a table and chairs. Outdoor grounds contained an emergency exit at the gates on each side of the house which does not contain any locks. The yard contains plants and succulents accessible to residents to participate in gardening activities. There were no bodies of water or firearms on the premise.

CONTINUED 809-C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COMFORT CARE HOME
FACILITY NUMBER: 198603154
VISIT DATE: 08/25/2021
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At approximately 9:45 a.m. LPAs toured the physical plant with staff member, Josefina Napiza and observed the following:
Bedroom # (1) contains 1 twin bed, 1 chair, 1 bedside table, chest with drawers, including overhead lighting.
Bedroom # (2) contains 1 twin bed, 1 bedside tables, chest with drawers, including overhead lighting.
Bedroom # (3) contains 2 twin beds, 2 bedside tables, chest with drawers, including overhead lighting.
Bedroom # (4) contains 1 twin bed, 1 bedside tables, chest with drawers, including overhead lighting.
Bedroom # (5) contains 1 twin bed, 1 chair, 1 bedside table, night stand, chest with drawers, including overhead lighting.
All bathrooms (bathroom #1 and bathroom #2) have a working toilet, faucet, wash basin. Bathroom #1 has a bathtub with a shower chair and Bathroom #2 contains a walk in shower which will accommodate non-ambulatory residents in a wheel chair and a storage cabinet with hygiene and grooming supplies and hygiene caddies. All bathrooms contain a shower hose with two grab bars in the shower, with non-slip surface on the shower floor and a raised toilet seat. Water temperature measured at 114.4 degrees Fahrenheit and 111.2 degrees Fahrenheit, respectively.
LPAs inspected the garage which contained a working washer and dryer, durable medical equipment, personal storage for resident belongings, emergency supplies, and continence and personal care supplies and located in locked cabinets.
All required postings were identified in the office area/hallway: theft/loss manual, bill of rights, resident council, neighborhood complaint policy, emergency disaster plan, ombudsman poster and let-us-know poster. The residence contains a telephone land line available for resident access. Fire Extinguisher is located in the hallway, mounted on wall fully charged. The facility has activity supplies, board games, books and reading materials available to the residents as described in the plan of operation. PPE and the hard copies of staff files and residents files are located in the living room in file cabinets locked/inaccessible to the residents.
LPAs inspected the food supply. Food supply was observed to contain a (2) day supply of perishables and a (7) day supply of non-perishables for all residents, which consisted of fruits and vegetables, meats, bread, cereals and canned goods. Kitchen cabinets included: dishware, glasses, cups, utensils, pots, pans, cooking equipment, working appliances observed to be in good repair. Knives, cutlery and other sharps were observed to be located in drawer locked and inaccessible to the residents. Cleaning agents, chemicals and toxins were locked in the garage inaccessible to the residents. Dishwasher in kitchen was observed to be in working order. Emergency food supply and emergency disaster supplies were located in the garage and contained additional food, clothing, blankets, continence supplies and bottled water available for resident use.
CONTINUED 809-C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COMFORT CARE HOME
FACILITY NUMBER: 198603154
VISIT DATE: 08/25/2021
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No deficiencies were observed at time of visit.

A copy of the report and appeal rights were provided to staff, Josefina Napiza.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC809 (FAS) - (06/04)
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