Comfort Cottages #1

Allegation investigated: Resident is left in bed for an extended period of time. Staff is not meeting resident's dietary needs. Staff do not treat resident with dignity or respect.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by Staff #1 at 8:25am. LPA met with Administrator (AD) Farooq Rashid and explained the purpose of the visit. LPA obtained the following files for Resident #1 (R1): Identification and Emergency Information, Physician Reports dated 1/18/2023 and 2/15/2022, Apprasial Needs and Services Plans dated 1/20/2023 and 2/14/2022, Resident Appraisal, RCFE Levels of Care Assessment Tool dated 2/14/2022, Hospice Proposed Services and Frequency, and Hsopice Flow Sheet from 7/24/2023-9/12/2023. Additional documents obtained include Durable Power of Attorney and Advance Health Care Directive paperwork and Superior Court of California Elder Abuse Restratiing Order dated 6/29/2023. Resident #1 (R1) moved into the facility on 2/14/2022. The signed Physician's Report and Appraisal Needs and Services Plan stated R1 had a primary diagnosis of Dementia with Lewy Bodies. R1 was on a (Continued on LIC 9099-C) Unfounded (Continued from LIC 9099) diet of puree thickened liquids and was Bedridden. The Resident Appraisal dated on 2/14/2022 noted Resident #1 (R1) arrived with a G-tube and received hospice services. The hospice nurse came one to three times per week, and the home health aide visited twice per week. Resident passed away on 2/12/2025 but was interviewed by the Department on 8/22/2023. It was alleged that Resident is left in bed for an extended period of time. LPA reviewed Physician's Reports from 2/15/2022 and 1/18/2023 which reported R1 was bedridden. Interviews with three of three staff stated that R1 was only able to be out of the bed and in a wheelchair for approximately fifteen minutes. Interviews with two of two witnesses stated R1 did not want to be out of bed and was comfortable. Both witnesses stated that the resident resided in the facility for three years and never had bedsores the entire three years. Staff constantly repositioned resident every two to three hours. Three of three staff and two of two witnesses denied the allegation. LPA interviewed three of three residents and all denied the allegation that they were left in bed for an extended period of time. One resident stated they cannot move about freely but staying in bed was a choice and that staff encourage the resident to get outdoors. LPA investigated the allegation that Staff is not meeting resident's dietary needs. Per Resident Appraisal dated on 2/14/2022, R1 had a G-tube, which was managed by hospice. Family and Power of Attorney (POA) visited often and would also assist with feeding R1. Per Physican's Report dated 2/14/2022; R1 was on a special diet of thickened, pureed foods due to a secondary diagnosis of Dysphagia. Interviews of three of three staff and two of two witnesses denied the allegation that Staff is not meeting resident's dietary needs and stated resident readily ate. Three of three residents were asked about food and dietary needs being met and three of three residents stated there is plenty of food and their dietary needs were being met. Lastly, it alleged that Staff do not treat resident with dignity or respect. Three of three staff and two of two witnesses reported that there were multiple visits by the Orange County Sheriff and paramedics. During one such visit, the Power of Attorney (POA) was present and asked who had called for emergency services since the POA did not request these services. Staff stated that if resident was asleep and did not answer the phone, that paramedics came and were told resident was unconscious; when in fact resident was asleep and was being visited by POA. R1 had a hard time holding the phone to FaceTime others and had difficulty (Continued on LIC 9099C-1) (Continued from LIC 9099-C) speaking for long periods of time. The Orange County Superior Court provided phone monitoring services for R1; to ensure R1 had privacy with phone calls; without staff assistance. LPA interviewed three of three residents and asked if they were afforded dignity and respect in their interactions with staff and one another. Three of three residents confirmed that they had the right to do what they wished, visitors could come and go and that staff did not invade their privacy. Based on LPA's record review, interviews and observations the allegations that: Resident is left in bed for an extended period of time, Staff is not meeting resident's dietary needs and Staff do not treat resident with dignity or respect are Unfounded. The allegations are false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Administrator Farooq Rashid and a copy of this report and LIC 811 was provided at time of visit.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 22-AS-20230815154644

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. There are four residents at the facility and there is one resident receiving hospice services currently. LPA met with Farooq Rashid, Administrator. LPA accompanied by Administrator began the tour of the inside and outside of the facility. LPA observed required department postings posted in the facilities bulletin board. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in spare refrigerator, freezer and pantry located in garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in hallway storage closet. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 112.6 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored in a locked storage cabinet in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors and carbon monoxide detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment. LPA observed that Continued on LIC809-C facility is equipped with solar panels, which would provide resources in case of a power outage. LPA observed a fire extinguisher mounted in the wall of the kitchen/dining room. Fire extinguisher was charged and dated December 30, 2025. Fire drills are conducted quarterly and the last fire drill the facility conducted was in January 3, 2026. LPA began review of records. LPA reviewed four resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 6, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by caregiver and LPA explained the nature of the visit. There are four residents at the facility and there is one resident receiving hospice services currently. LPA began the tour of the inside and outside of the facility. LPA observed required department postings posted in the facilities bulletin board. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in spare refrigerator, freezer and pantry located in garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in hallway storage closet. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 109.4 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored in a locked storage cabinet in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors and carbon monoxide detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment. LPA observed that facility is equipped with solar Continued on LIC809-C panels. LPA observed a fire extinguisher mounted in the wall of the kitchen/dining room. Fire drills are conducted quarterly and the last fire drill the facility conducted was in September 2024. LPA began review of records. LPA reviewed two resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by caregiver and LPA explained the nature of the visit. Farooq Rashid, Administrator arrived shortly after and met with LPA. There are two residents at the facility and there is one resident receiving hospice services currently. LPA accompanied with caregiver began the tour of the inside and outside of the facility. LPA observed required department postings posted in the facilities bulletin board. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in spare refrigerator, freezer and pantry located in garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in hallway storage closet. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 106.3 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored in a locked storage cabinet in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment. LPA observed a fire extinguisher with service date of July 14, 2023, in Continued on LIC809-C kitchen/dining room. Fire drills are conducted quarterly and the last fire drill the facility conducted was in March 2024. LPA began review of records. LPA reviewed two resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 20, 2024