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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603154
Report Date: 09/11/2023
Date Signed: 09/11/2023 03:07:30 PM

Document Has Been Signed on 09/11/2023 03:07 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, 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: 6DATE:
09/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Administrator Peter NoraTIME COMPLETED:
03:24 PM
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On 9/11/23 at 12:52 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Comfort Care Home. Upon arrival LPA was greeted by Direct Support Professional (DSP) Josephine Napiza who contacted the Administrator, Peter Nora. The Administrator’s arrived at 1:10 p.m., and LPA explained the reason for the visit. This home is licensed to serve age range 60 and over. Approved hospice waiver for 6 residents. There were (6) clients in care during the time of this visit. The last emergency disaster/fire drill was conducted on 8/01/23. The Administrator Certificate expires on 2/14/2024 #6031894740. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (6) resident files, medications, and medication administration records for (6) residents.

This home contains 5 bedrooms, 2 bathrooms, living room, Living room/office, kitchen, dining room and an attached garage. LPA toured the physical plant with the Administrator. and observed all (5) resident bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. The temperature measured at 114.0*F-114.1*F. The smoke detectors were battery operated and tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (1) fire extinguishers located in kitchen fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked in a cabinet. The toxins and cleaning supplies was locked underneath kitchen sink with cleaning agents and toxins. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home.
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COMFORT CARE HOME
FACILITY NUMBER: 198603154
VISIT DATE: 09/11/2023
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The outdoor grounds were toured and inspected, and the patio was well maintained with a shaded seating area accessible for client use. The garage contained a working washer and dryer, with cabinetry that contained emergency supply kits, bottled water, toiletries, personal care supplies, and PPE supplies.

The Living room contained a non-working fireplace contained a covered screen so that it was inaccessible to the clients.

Exit interview conducted with Peter Nora, Administrator, a copy of this report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC809 (FAS) - (06/04)
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