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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006351
Report Date: 08/24/2023
Date Signed: 08/24/2023 02:40:36 PM

Document Has Been Signed on 08/24/2023 02:40 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COMFORT KEEPERS HOME CARE IIFACILITY NUMBER:
306006351
ADMINISTRATOR:MITRICA, CONSTANTINFACILITY TYPE:
740
ADDRESS:7241 E COLUMBUS DRIVETELEPHONE:
(714) 280-0380
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY: 6CENSUS: 4DATE:
08/24/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Constantin Mitricia - AdministratorTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced inspection to the facility for purpose of conducting a pre-licensing inspection (change of ownership) with clients in care. LPA arrived at the facility at 1:00 pm and was greeted and granted entry by designated Administrator (AD) Constantin Mitrica. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden clients was received by Community Care Licensing (CCL) on 5/4/2023.

Structure:
The facility is a one-story home with four resident bedrooms, two resident bathrooms, one staff bedroom, one staff bathroom, living room, kitchen, dining room, an attached two car garage and backyard. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the dining room. There is a back yard with one exit gate. The facility has three shaded seating areas. LPA did not observe any obstacles or hazards in the backyard.

Client Bedrooms:
All resident bedrooms had the necessary furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Bedroom 5 has a sliding door leading to the backyard. This door has an alarm on it to notify staff if it is opened.

Signal System:
The facility utilizes a signal system for each resident. The monitor for the system is located in the living room. Each resident is associated with a different number that will appear on the signal system’s monitor.

Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked under the kitchen sink and in the garage.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: COMFORT KEEPERS HOME CARE II
FACILITY NUMBER: 306006351
VISIT DATE: 08/24/2023
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Medications, First-Aid Kit & Book: Medication and First Aid Kit will be stored in a locked cabinet in the kitchen. The first aid kit has all the required elements.

Resident & Staff Files: Records are kept in a closet near the entryway of the house. All staff members have been background cleared and are associated. Resident files each had the required paperwork.

Fire Extinguisher: LPA observed one fire extinguisher to be fully charged as indicated by the arrow pointing in the green zone. LPA observed the service tag indicates the fire extinguisher was last serviced on 6/5/23.

Reading Material, Games, Equipment & Materials: The facility has books and games in the dining room. The facility also has a music therapist come to the facility to get the residents to participate in art.

Fire clearance: Was approved by a fire inspector of Anaheim Fire Department on 05/23/2023.

Component III: Conducted at the Pre-Licensing visit

Bathrooms: The bathrooms have working plumbing. Hot water measured at 112.5 degrees Fahrenheit in the bathroom between Bedrooms 2 and 4 and 107.5 degrees Fahrenheit in the bathroom inside Bedroom 3.

Linens & Hygiene Supplies: A supply of extra linen is stored in the closet in Bedroom 3
Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review
Food Service: There is 2-day supply of perishable and a 7-day of non-perishable food on hand.

Smoke Detectors: Smoke detectors were observed to be separate Smoke & Carbon Monoxide detectors that are stationed throughout the home. Both detectors were tested and observed to be operational. The facility also has one fire door that closes when the smoke detector goes off.

Appliances: Stove burners, oven, refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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