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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701130
Report Date: 02/11/2026
Date Signed: 02/11/2026 02:50:02 PM

Document Has Been Signed on 02/11/2026 02:50 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:COMFORTS OF HOME GAVIRATEFACILITY NUMBER:
342701130
ADMINISTRATOR/
DIRECTOR:		PARAS, FAITHFACILITY TYPE:
740
ADDRESS:9823 GAVIRATE WAYTELEPHONE:
(916) 897-9465
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 5DATE:
02/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:22 AM
MET WITH:Faith ParasTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 2/10/2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced to conduct the annual inspection visit. LPA initially met with staff on duty (S1) and stated the purpose of the visit. The Administrator, Faith Paras (AD), arrived shortly after.

Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, up to 6 may be non-ambulatory.

Initial Observation: Present were 4 residents with 2 staff on duty. One resident is currently out. LPA observed required posters and facility license. Room temperature was at 74 degrees Fahrenheit upon arrival. 2 of the residents were in the family room watching TV.

Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 6 of 6 resident bedrooms and 2 bathrooms. The hot water temperature was measured at 118 degrees Fahrenheit. The bathroom by the dining table houses a closet where they store cleaning solutions. The closet door can be unlocked without a key which makes it accessible to residents in care. The laundry detergent was observed in a cabinet above the washer. This cabinet can be unlocked without a key by anyone.

Fire extinguisher was observed and was last inspected on 1/23/25. Smoke detectors were observed throughout. LPA observed at least one carbon monoxide monitor.

LPA observed at least seven-day non-perishable and two-day perishable food supplies. Kitchen refrigerator and freezer were maintained at regulatory temperature. LPA observed medication box in the kitchen refrigerator to be unlocked and accessible to residents in care. LPA also observed other medication next of the box. Per administrator, that medication belong to a former resident

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COMFORTS OF HOME GAVIRATE
FACILITY NUMBER: 342701130
VISIT DATE: 02/11/2026
NARRATIVE
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LPA also observed sharp objects to be accessible to residents including knife and scissors in the dishwasher, meat thermometer in one of the kitchen drawer, and scissors in Room #3.

The garage is locked and cannot be access without a key.

Outdoor area was inspected. The storage shed at the backyard was observed to be unlocked and accessible to resident. This shed stores sharp objects - gardening tools. The shut off valves - electric, water and gas - were located. Per AD, she does not know how to shut off the gas and no tools were available to be used to shut the gas off during this visit.

Record Reviews: Review of 4 of 5 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Residents did not have PRN Authorization Letter on file. Per AD, she will obtain one for each residents. LPA did not find hospice care plan for those resident(s) receiving hospice services. Per AD, she will obtain one from the hospice agency.

LPA conducted medication review for 2 residents. Per review, one resident has an order for Famotadine 20mg but the medication on hand is 40mg. Further review, a resident was given PRN but no proper recording of the PRNs including record of resident's reaction to the medication after being administered.

Review of 4 staff files included but not limited to review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Administrator has a current Administrator Certificates.

LPA also reviewed fire drill/disaster drill records; facility conducts every quarter

Documents Requested: LPA obtained a copy of updated Liability Insurance Certificate, LIC500, LIC610 and LIC308.

Per the California Code of Regulations, Title 22, Division 6, Chapter1 & 6, deficiencies were cited. Exit interview was conducted. A copy of the report and appeal rights were provided upon exit.

NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/11/2026 02:50 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/11/2026 at 02:02 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORTS OF HOME GAVIRATE
FACILITY NUMBER: 342701130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited. The closet that stores cleaning supplies and the cabinet that stores laundry detergents can be unlocked without a key and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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Per administrator, she stated she will get a lock with a key.
Administrtor will submit a photo of the new locks by POC due date.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. During medication reviews, the dosage of one resident's medication did not match with the physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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Administrator will submit a written plan on how to ensure the right medication is received. Plan to be submitted by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/11/2026 02:50 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/11/2026 at 02:02 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORTS OF HOME GAVIRATE
FACILITY NUMBER: 342701130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Resident medications were observed in the kitchen refrigerator, unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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Corrected on site: administrator put a padlock on the medication box.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 02/11/2026 02:50 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/11/2026 at 02:02 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORTS OF HOME GAVIRATE
FACILITY NUMBER: 342701130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed furniture bllocking the exit door for Room #5, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2026
Plan of Correction
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Corrected on cite: Administrator removed the furniture (lounge chair and ottoman) away from the exit sliding door.
Type B
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Residents did not have PRN Authorization on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2026
Plan of Correction
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Per Administrator, she will obtain a PRN Authorization Letter for each residents in care signed by their physician. Submit proof of completed PRN Authorization Letter by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 02/11/2026 02:50 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 02/11/2026 at 02:02 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORTS OF HOME GAVIRATE
FACILITY NUMBER: 342701130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. During one resident's medication review, there was no proper documentation of PRNs that were administered, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2026
Plan of Correction
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Per Administrator, she will retrain staff on documenting PRN administrations. Submit staff training by POC due date.
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. One resident who is receiving hospice did not have their hospice care plan avaialbe for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2026
Plan of Correction
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Per Administrator, she will obtain a copy of resident's hospice care plan. Submit care plan by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2026


LIC809 (FAS) - (06/04)
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