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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700327
Report Date: 07/22/2022
Date Signed: 07/22/2022 02:19:38 PM

Document Has Been Signed on 07/22/2022 02:19 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:A & V COMFORT HOME CAREFACILITY NUMBER:
342700327
ADMINISTRATOR:VERES, VASILEFACILITY TYPE:
740
ADDRESS:5604 NORTH AVETELEPHONE:
(916) 487-7015
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 6DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Maria Veres, Licensee and Debbie Pindling, caregiver TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Maria Veres, Licensee, and explained purpose of inspection. LPA observed, Debbie Pindling, caregiver, also present. LPA observed (5) residents to be eating lunch in the common area and (1) resident to be eating lunch in her room. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (4) residents. Currently, there is (1) resident on hospice. Licensee stated she will re-submit a hospice waiver increase request for (6) residents since it was not received bv the Department. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask.

LPA and Licensee toured the interior and exterior of the facility including the common areas, resident bedrooms, resident bathrooms (2), kitchen, and laundry. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout.. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels, and hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, locked sharps and medications in the kitchen and locked toxins in the laundry room. LPA observed the inside temperature measured at 76*F and observed the hot water temperature to be 120*F based on a reading from the water heater. LPA observed an outside shed used to store supplies and an exit gate that is unlocked from the inside. Discussed vaccination status of residents/staff, eligibility for first/second boosters and visitation protocols. All staff are cleared/associated. Administrator certificate #6019191740- exp 11/16/22. All required postings up. LPA requested an updated copy of LIC500, LIC308 and a copy of the current liability insurance by provided to the Department by 7/30/2022.

Exit interview. There were no deficiencies observed during today's inspection.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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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