565850305-2-17-2023-29-AS-MARO-CP5QFE-20230217110748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850305
Report Date: 02/17/2023
Date Signed: 02/17/2023 11:08:24 AM

Document Has Been Signed on 02/17/2023 11:08 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ELDERLY COMFORT CARE, LLC		FACILITY NUMBER:	565850305
ADMINISTRATOR:	LEITERMAN, KATHLEEN		FACILITY TYPE:	740
ADDRESS:	458 S WALTER AVE		TELEPHONE:	(818) 926-9178
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91320
CAPACITY: 6		CENSUS: 0	DATE:	02/17/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Favar Miranda & Kathleen Leiterman		TIME COMPLETED:	11:30 AM

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Licensing Program Analyst (LPA), Martha Arroyo conducted a pre-licensing visit to this property at 9:00am on 02/17/2023 and met with Applicant Representative Favar Miranda and Administrator Kathleen Leiterman. The applicant has obtained fire clearance for a total capacity of five (5) non-ambulatory residents, and one (1) bedridden resident in bedroom #1 for a total capacity of six (6) residents.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. At 9:30am, all hard-wired smoke alarms, fire alarm, and carbon monoxide detectors were tested and function properly. LPA observed two (2) fire extinguishers to be fully charged.

There are three (3) double occupancy bedrooms for resident use. There is one (1) staff room for the live-in staff. Each bedroom is equipped with clean mattresses, pillows, and bedding. There is sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. The facility has two (2) bathroom for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Night-lights were present throughout. Hot water measured in each bathroom; both bathrooms measured at 105.3 degrees Fahrenheit.

LPA toured the kitchen area at 9:15am. The facility has at least seven (7) day supply of non-perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives are stored in two (2) drawers locked adjacent to the refrigerator. The kitchen has a sufficient supply of plates, cups, cook ware and utensils

The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for six (6) residents at the same time in the dining room table. A working telephone is present. There are activity supplies for residents.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELDERLY COMFORT CARE, LLC	FACILITY NUMBER: 565850305
	VISIT DATE: 02/17/2023

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Report Continued from LIC 809...

Medications will be stored and locked in the closet by the main hallway. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Facility records will be stored and locked in a cabinet inside the facility office.

Garage: The garage is attached to the house and will be locked at all times. Detergents, disinfectants, and cleaning supplies are stored and inaccessible. There will be no firearms/ammunition stored on the property. Laundry room was observed locked and inaccessible.

The facility has required postings, including emergency exit plan, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights.

Facility will have one central entry point designated for universal screening. Alcohol-based hand sanitizer and masks available upon entry. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE).

The exterior passageways were clean and clear of any obstructions. There is one (1) self-latching gate for emergency use. There are no bodies of water on the premises at the time of the visit. LPA observed the backyard, which has a covered outdoor area for resident use. Physical plant is consistent with the submitted facility sketch/floor plan.

The physical plant of this facility location is in compliance with Title 22 regulations at this time.

Comp III conducted with Applicant Representative and Administrator.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to admit any new clients and begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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