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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006547
Report Date: 03/18/2025
Date Signed: 03/18/2025 04:40:20 PM

Document Has Been Signed on 03/18/2025 04:40 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COMFORT FIRST HOME CAREFACILITY NUMBER:
306006547
ADMINISTRATOR/
DIRECTOR:		PHAM, MINHFACILITY TYPE:
740
ADDRESS:645 S MAGNOLIA AVETELEPHONE:
(714) 244-5687
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 6DATE:
03/18/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Administrator- Minh PhamTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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On March 18, 2025, at 9:50 AM, Licensing Program Analyst (LPA) Edward Kim conducted a case management- deficiency visit unrelated to a complaint investigation (Complaint# 22-AS-20250305152012).

On March 10, 2025, during a complaint visit, LPA observed the following deficiencies:

1. S3 is working in the facility without background clearance.
2. Two individuals who were identified as friends of S3 slept in the facility from March 7, 2025, through March 10, 202,5 without background clearance.
3. The facility is not maintaining records for all residents.
4. The facility is not maintaining records for all staff.

Deficiencies were cited during the inspection visit according the California Code of Regulations Title 22 Division 6 Chapter 8. A civil penalty was assessed at this visit.

An exit interview was conducted, and a copy of this report and the appeal rights were provided to Administrator Minh Pham.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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 03/18/2025 04:40 PM - It Cannot Be Edited


Created By: Edward Kim On 03/18/2025 at 10:09 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COMFORT FIRST HOME CARE
FACILITY NUMBER: 306006547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2025
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working, residing, or volunteering in a licensed facility: 2) Obtain a California clearance or a criminal record exemption...
This requirement is not met as evidence by:
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Licensee states they will have background clearance on S3 before they are allowed back on the facility. Licensee will send proof of completion background clearance and association to CCLD through email to edward.kim@dss.ca.gov by POC due date March 18, 2025.
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Based on observation, record review, and interviews, the licensee did not comply with the section cited above. LPA Kim observed S1 working, and two visitors resided in the facility not having background clearance. This poses an immediate health and safety risk to persons in care.
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Type B
04/01/2025
Section Cited
HSC87412(a)

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87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee.

This requirement is not met as evidence by:
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Licensee states they will provide LIC501, LIC503, and training hours for S1-S3 to CCLD through email to edward.kim@dss.ca.gov by POC due date April 1, 2025.
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Based on observation, interviews, and record review, the Licensee did not comply with the section cited above. LPA Kim observed personnel records of S1-S3 were missing LIC503, LIC501, and training hours. This poses a potential health and safety risk to persons 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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2025 04:40 PM - It Cannot Be Edited


Created By: Edward Kim On 03/18/2025 at 10:16 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COMFORT FIRST HOME CARE
FACILITY NUMBER: 306006547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2025
Section Cited
CCR
87506(a)

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87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...readily available to facility staff and to licensing agency staff.

This requirement is not met as evidence by:
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Licensee states they will maintain records for the indviduals at the facilty with physician's report, pre-appraisal, LIC621, consent forms, and LIC613C and send proof to CCLD via email to edward.kim@dss.ca.gov by POC due date April 1, 2025.
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Based on observation, interviews, and record review, the Licensee did not comply with the section cited above. LPA Kim observed individuals R1-R6 did not have residents with admissions agreement, physician’s report, pre-appraisal, and other pertinent documents.
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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