Comfort Care Assisted Living Facility

Type of visit: Required - 1 Year

On 09/09/26, at 9:05AM, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA met with conducted Susanna Avetian, Manager/Caregiver. A tour of the physical plant was conducted at around 9:55AM and the following was noted: The facility has a total of four (04) bedrooms and two (2) and a half (1/2) bathrooms. The facility is fire cleared for six (06) non-ambulatory of which one (01) may be bedridden and a hospice waiver for six (06). The facility is currently occupying six (06) residents. KITCHEN: The facility has a kitchen area that is equipped with a refrigerator, stove/oven and sink. Knives is kept locked in a kitchen drawer on one (1) of the top cabinets. Cleaning supplies/detergents are kept locked underneath the kitchen sink. Medications are kept locked and inaccessible in a white cabinet in the dining/living room area. There is a fire extinguisher that is fully charged and dated 12/25. BEDROOMS: There are four (4) bedrooms. Two (2) bedrooms are shared and two (2) bedrooms are single occupied. All bedrooms have beds, sheets, televisions and working lights. LIC 809-C-continued BATHROOMS: The facility has two (2) and a half (2 1/2) bathrooms. The two bathrooms, designated for resident use were observed to have proper fixtures, grab bars, and non-skid mats. The hot water temperature measured between 116.8 degrees. Living Room/Dining Room Area: LPA toured all common areas to ensure everything is in good repair. Both living room and dining room have sufficient space and lighting. Floors were clean and maintained. Entrance/exits are clear of obstruction. Laundry/Washer/dryer: is located next to the kitchen area. Administration: LPA reviewed six (6) resident files and two (2) staff files. The administrative license is current and against the wall with a date of 04/15/28. The fire/evacuation drill was last conducted in 08/20/2026. There are signs against the wall- Ombudsman, Family Council, Rights of Resident Council, Rights of Resident Councils, Emergency and Disaster Plan, Personal Rights, Facility Sketch, YES and the license is also against the wall. The liability insurance expires 08/01/27. Outside areas: LPA toured the outside area of the facility to insure the front and back yards of the facility is clear of obstruction. There is sufficient yard space to keep outdoor furniture. Passageway/exits to both side gates are free of any hazards. There is no swimming pool or any other bodies of water. There are two (2) sheds that are full of hygiene and incontinence materials. Garage: There is no garage. There are cameras in the common areas. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Sep 9, 2026

Type of visit: Required - 1 Year

At 9:45a.m., Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection to the facility. Upon arrival, LPA met with Manager/Caregiver whom granted entry to the facility and explained the reason for the visit. Later Licensee joined today’s visit. At approximately 10:15a.m., LPA and Manager/Caregiver conducted a physical plant tour inside and out. During the tour, LPA observed that the facility is a one-story home located in a residential community. The home has four (4) bedrooms, two (2) full bathrooms, one (1) 1/2 bathroom; living room / dining area, and kitchen. There is a small office located next to front door. Required postings were observed in the entry area. The smoke alarms are operational, located in each bedroom and hallways. Front yard landscape is in good condition at time of this visit. There is a carbon monoxide detector that functions properly. The fire extinguisher is in the kitchen with purchased date of 12/10/2024. During the visit the facility is at 74 degrees Fahrenheit. The facility is licensed to serve 6 (six) non- ambulatory residents ages 60 and over of which 1 (one) may be bedridden and facility is approved to retain six (6) residents on hospice. The facility cares for elderly residents with dementia. Fire Emergency drill was last conducted on 11/10/2025. The facility is currently occupying five (05) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Kitchen: LPA observed kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found at least two (02) days perishable and seven (07) Cont. on LIC 809-C Cont. from LIC 809 days non-perishable food at the facility that is properly stored. Frozen foods are wrapped and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Toxic cleaning supplies were stored and locked away in the kitchen cabinet and laundry room closet. Medications: Medications are in a centrally stored and locked medication cabinet in office area, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the resident’s doctor. First-aid has all proper items and were observed to be stored in a locked cabinet in the office area. Laundry Room: LPA observed washer and dryer machines located adjacent to the kitchen. Bedrooms: All residents bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Hallways are well lit. Linens are stored in resident room closet and observed to have ample supply of clean linen, comforters, and towels in facility. Bathrooms: LPA observed bathrooms to be clean, sanitary and with necessary supplies. The appropriate grab bars and mats in the showers. Hot water temperature measured at a range of 118.0°F to 118.4°F and within the required range. Resident’s personal hygiene supplies are kept separate in plastic containers. Towels and washcloths are not shared. Common Areas: These included the dining area and living room for residents. The common areas were properly furnished and observed to be in good repair. Residents dining table fits six (06) residents. No obstructions and/or tripping hazards throughout the facility. Surrounding Grounds: Entry and exits were free of obstruction. The facility has appropriate outdoor furniture with a shaded covered area for residents and visitors. The outdoor area was enclosed, and no bodies of water were observed. Two (2) storage sheds with extra supplies, observed to be locked and inaccessible to residents in care. Staff Files: Staff files all have criminal record clearances and are associated to facility. Staff have current first aid and training documentation showing training completed. Administrator's certificate was observed to be current. Resident Records: All five (05) resident records were reviewed. Residents’ records are complete and current at this time. Staff and residents files locked and inaccessible. Residents were also interviewed. Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2025

Allegation investigated: Staff neglect resulted in a resident sustaining a burn. Staff did not provide reasonable accommodation to the resident.

Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced subsequent complaint visit to this facility to investigate the above allegation and deliver findings. LPA met with facility manager, Susanna Avetian and explained the reason for the visit. Regarding the allegation: Staff neglect resulted in a resident sustaining a burn. To investigate this allegation LPA de la Cerra conducted an initial visit on 12/16/24 and LPA requested pertinent documents relevant to the investigation at 11:00AM, conducted and interviewed resident and facility staff member between 11:15AM – !2:15PM. On 02/12/25, at 12:30PM LPA de la Cerra asked for the census, LIC500 and LIC9020 upon arrival. LPA interviewed additional residents, conducted a physical tour, gathered additional pertinent documents. It was alleged that while bathing R1 on 12/11/24, staff failed to check the temperature of the water which resulted in R1 getting burns on her back and lower back side. Unsubstantiated Interviews with S1 and S2, revealed that the morning of 12/11/24 was the onset of R1’s diarrhea and a few more loose bowels thereafter. S2 with the help of a hospice worker - W3 repeatedly cleaned R1 by washing off the loose bowels all over R1. S1 and S2 informed LPA that during every cleaning and washing of R1, S2 and W3 constantly checked the water temperature to prevent R1 from getting scalded. In the afternoon R1 was taken to the hospital as ordered by R1's conservator (W2). LPA de la Cerra’s review of the police investigation report dated 12/12/24 by officer (W1) from Glendale Police Department revealed that during the interview between R1 and the officer at the hospital, R1 was alleging that facility staff burned R1 on the back side of their body. The officer (W1) then stated on their police investigation report that five (5) nurses were asked to shift R1’s body to the left side and shift the body to the right side to examine R1 for burns. Officer (W1) noted on the report that all five (5) nurses and officer (W1) did not observe any burns on R1. Futhermore, LPA’s interview with R1’s conservator (W2) revealed that R1 has a history of making false allegations. Therefore, based on interviews, record reviews and observations, this allegation is deemed unsubstantiated at this time. Regarding the allegation: Staff did not provide reasonable accommodation to the resident. To investigate this allegation LPA de la Cerra conducted an initial visit on 12/16/24 and LPA requested pertinent documents relevant to the investigation at 11:00AM, conducted and interviewed resident and facility staff member between 11:15AM – !2:15PM. On 02/12/25, at 12:30PM LPA de la Cerra asked asked for the census, LIC500 and LIC9020 upon arrival. At 12:30PM LPA interviewed additional staff and residents, conducted a physical tour, gathered additional pertinent documents. It was alleged that facility did not accommodate R1 with a bed and oxygen machine. During LPA’s facility tour, LPA checked R1’s room at the facility and observed a bed. S1 also showed LPA some pictures S1 previously took of R1 laying on the assigned bed at the facility. Review of R1’s medical records revealed that there weren't any prescription for a medical oxygen machine. Furthermore, LPA’s interview with two (2) out of four (4) residents stated that the facility always provides reasonable accommodations. LPA’s interview with R1’s conservator (W2) revealed that R1 has a history of making false allegations. Therefore, based on interviews, record reviews and observations, this allegation is deemed unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report was signed and issued.the state’s words, verbatim · CDSS document, Feb 12, 2025 · control 31-AS-20241215221640

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required- 1 year visit. LPA met with House Manager Susanna Avietian and explained the purpose of the visit. Structure: Facility is a one-story family home with four (4) bedrooms, two (2) full bathrooms, one (1) 1/2 bathroom; living room / dining area, and kitchen. There is a small office located next to front door. Staff and residents’ files are locked and inaccessible. Bedrooms 1, 2 and 4 have direct exits. All exits are equipped with auditory devices with alert feature to monitor exits. Front yard landscape is in good condition at time of visit. Washer/Dryer appliances are in laundry area. Bedrooms #1, 2, 3, and 4 are approved for non-ambulatory clients and bedroom # 1, 2, or 4 can be bedridden. All bedrooms are clean and completely furnished. The bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested throughout the facility and maintained within the required range of 118.1*F. The fire extinguisher was last serviced in January of 2024. Fire detector is operable as well as carbon monoxide detectors. The backyard has a shaded area with furniture. There are no bodies of water. There is sufficient perishable and non-perishable food. Hazardous chemicals are kept locked under the kitchen sink and are inaccessible to residents in care. There is one complete first aid kit. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 3, 2024

Allegation investigated: Staff unlawfully evicted a resident

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation, LPA met wiith Manager Susanna Avetikyan and explained the reason for the visit. It was reported that staff unlawfully evicted a resident. To investigate this allegation on 05/29/24 between 10:45am and 11:00am, staff interviews were intitiated. Interviews revealed that staff did not evict Resident #1 (R1). R1 was sent to the hospital on 5/19/24, due to expolosive diarrhea, and once there the hospital refused to disclose their diagnosis. Facility requested many times for R1's information to be provided, but it was not. Staff told hospital that they could not accept R1 until their diagnosis was disclosed. On 5/21/23, R1's responsible party came to the facility and collected their belongings. Based on interviews, there is not sufficient information to support this allegation. Hence, this allegation is UNSUBSTANTIATED. Unsubstantiated No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 29, 2024 · control 31-AS-20240522222103

Allegation investigated: Staff did not ensure resident's toileting needs were properly met

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegatoin. LPA met with Manager Suzanne Avetian and explained the reason for the visit. It was reported that staff did not ensure resident's toileting needs were properly met. Resident #1 (R1) has had uncontrolled diarrhea and vomiting for approximately two weeks. To investigate this allegation on 5/21/2024, between 10:30am and 11:15am, staff interviews were initiated. Interviews revealed that R1 has been a resident at the facility for less than a month. About two weeks ago, R1 developed uncontrolled diarrhea. Staff has been doing there best to meet R1's toiletting needs by changing the diaper as often as needed and cleaning them. On 5/19/2024, R1 was sent to the hospital with the consent of their next of kin. R1's responsible party refuses to disclose theiir medical diagnosis to staff. Facility staff d0 not know what is wrong with R1. Between 11:20am and 11:40am, LPA reviewed facility records. Records confirmed what staff told LPA. Continue on 9099C Unsubstantiated Based on interviews and records review there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 21, 2024 · control 31-AS-20240520133124