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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426081
Report Date: 11/17/2023
Date Signed: 11/20/2023 07:28:53 AM

Document Has Been Signed on 11/20/2023 07:28 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:COMFORT HOME 2FACILITY NUMBER:
366426081
ADMINISTRATOR:LAL, HARISH K.FACILITY TYPE:
740
ADDRESS:7092 PROVIDENCE WAYTELEPHONE:
(909) 371-3427
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 4DATE:
11/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee Sue LalTIME COMPLETED:
04:45 PM
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On 11/17/2023 at 01:40 PM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to initiate a Case Management visit. LPA Brown was greeted and granted entry by a staff member and Licensee Sue Lal was contacted and informed of the visit. LPA Brown explained the purpose of the visit to Licensee Lal. The investigation consisted of observation, interviews, and a review of pertinent documentation.

On 11/17/2023 at 02:00 PM, LPA Brown toured the facility with Staff #2 (S2) and observed the side gate secured and locked with padlock. LPA Brown informed Licensee Sue Lal that deficiency will be issued as they did not comply with the regulation by locking the side gate/perimeter fence gate in a manner that residents are unable to exit without assistance. This poses an immediate health, safety, and personal rights risk to residents in care.

Moreover, during the tour of the facility on 11/17/2023, LPA Brown observed the half bed rails on Resident #3 (R3) and no written order from R3's physician indicating the need for the postural support maintained in R3 facility record. LPA Brown informed Licensee Lal that deficiency will be issued as this poses potential health, and safety risk to residents in care.

An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and provided to Licensee Sue Lal.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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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Document Has Been Signed on 11/20/2023 07:28 AM - It Cannot Be Edited


Created By: Melody Brown On 11/17/2023 at 04:07 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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: COMFORT HOME 2
FACILITY NUMBER: 366426081

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2023
Section Cited
CCR
87705(I)(2)

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87705 Care of Persons with Dementia: (I) The following initial and continuing requirements shall be met by the licensee to lock the exterior doors or perimeter fence gates: (2) The Licensee shall ensure that the Fire Clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by:
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The licensee agrees to remove the lock and agree to not lock the perimeter fence gate without Licensing and Fire Marshall approval. Caregiver unlocked gate during visit. Plan of Correction (POC) cleared.

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Based on observation,interview and records review, the Licensee did not comply with the regulation by locking the side gate/perimeter fence gate in a manner that residents are unable to exit without assistance. This poses an immediate health, safety, and personal rights risk to residents in care.
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Type B
12/04/2023
Section Cited
CCR87608(a)(3)

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87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency... This requirement is not met as evidenced by:
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The Licensee stated to submit written order from R3's physician indicating the need for the postural support and submit letter to Community Care Licensing Division (CCLD) requesting approval for R3 half bedrail at the facility by Plan of Correction (POC) due date.
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Based on observation, interview andr ecord review, the licensee did not comply with the section cited above by having Resident #3 (R3) half bed rail with no written order from R3's physician indicating the need for the postural support maintained in R3 facility record which poses a potential health, safety or personal rights risk to residents 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
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