Comfort & Joy Living

Allegation investigated: Lack of supervision/Neglect resulting in resident injury Staff did not provide incontinence care

icensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to further investigate and deliver findings regarding the above complaint allegations. The investigation included facility visits, interviews with staff, residents, outside sources, and a review of facility records. On October 16, 2024, the Community Care Licensing Division (CCLD) received a complaint alleging a lack of supervision/Neglect resulting in resident injury, and the staff did not provide incontinence care. More specifically, the reporting party (RP) alleged R1 had a bruising on the forehead and skin irritation in the perineal area. (Continued on LIC9099C) Unsubstantiated (Continued from LIC9099) Resident #1 (R1) began residency at the facility on December 2, 2023, and remained at the facility until September 25, 2024. Physician’s report dated November 8th, 2023 indicates that R1 has a diagnosis of unspecified Alzheimer's Disease and is non-ambulatory. R1 required assistance with all activities of daily living, including incontinence care, repositioning, and hydration. Physician’s orders included maintaining adequate fluid intake and the use of a barrier cream due to skin sensitivity. R1 had a documented history of constipation , hemorrhoids as well as intermittent episodes of dizziness and syncope prior to admission. The Department reviewed physician’s reports and interviewes with OS1 confirmed R1’s medical history and compliance with physician’s orders while at the facility. OS1 stated that R1 was doing well at the facility and that staff followed care instructions, including the use of barrier cream. Progress notes from a Home Health Care agency dated September 27, 2024, confirmed that R1 had no inflamed hemorrhoids, no stage 1–4 pressure injuries, and no documentation of a bruise on the forehead. Department Interview with Staff #1(S1) revealed they witnessed R1 leaning on bed rail and causing redness however, no major bruising was witnessed. Based on interviews with outside sources and staff and and Records review a preponderance of evidence did not exist to prove that the alleged violations occurred. Therefore, the allegations were UNSUBSTANTIATED. An exit interview was conducted with LIcensee/Administrator KIngsley Okoro, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 08-AS-20241016165140

Allegation investigated: Staff are using a full bed rail for resident without a waiver/Physicians order Staff are restraining a resident

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. The investigation included facility visits, interviews with staff, residents, outside sources, and a review of facility records. On December 09, 2024, the Community Care Licensing Division (CCLD) received a complaint alleging that staff used a full bed rail for Resident #1 (R1) without a waiver or physician’s order and that staff restrained R1. Department records review and Interviews revealed R1 was admited to Hospice on November 8, 2024 and had orders for full bed rails. Documents and interview with OS1 further reveal they observed R1 four (4) times in November 2025 and three(3) times in December and did not observe conserns of restraints either by R1 sitting in chair or while in bed. During LPA’s visit on December 16, 2024, R1 was observed alert and seated in a recliner with no bed rails in use. Based on interviews and records review, a preponderance of evidence did not exist to prove that the alleged violations occurred. Therefore, the allegations were UNSUBSTANTIATED. An exit interview was conducted with LIcensee/Administrator KIngsley Okoro, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 11, 2026 · control 08-AS-20241209104430

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced continuation of the Required Annual Inspection. LPA was allowed entry and discussed the purpose of the visit with Licensee/Administrator Kingsley Okoro. According to the facility’s license, the facility has a maximum capacity of six (6)residents. Four(4) of which may non-ambulatory in rooms #2, #5, and #6 and one (1) may be bedridden in Room #3 . Hospice waiver approved for five (5) residents. This facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by Administrator toured the interior and exterior of the facility, and continued the inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Medications were labeled, as required, and stored in locked areas. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. LPA interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. No deficiencies were cited during today’s visit. An exit interview was conducted with LIcensee/Administrator Okoro to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to complete a Change of Ambulatory/Non-Ambulatory/Bedridden capacity application process submitted 10/06/25. LPA introduced herself, explained the purpose of the visit and was allowed entry into the facility by LIcensee/Administrator KIngsley Okoro. The Licensee requested approval to a maximum capacity of six (6) residents. Four(4) of which may non-ambulatory in rooms #2, #5, and #6 and one (1) may be bedridden in Room #3. The fire department inspection was completed on October 23, 2025 and approved on November 3, 2025. LPA toured the facility and confirmed that all clients are now residing in the new non-ambulatory and approved bedridden bedrooms. This Change of Ambulatory/Non-Ambulatory/Bedridden capacity application is complete. The information has been sent to the CCLD management team to update the current license. No new deficiencies were identified or cited during today's visit. An exit interview was conducted with Licensee/Administrator Okoro. A copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided and signature below confirms receipt of the documents.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to issue a deficiency based on observations from a annual inspection on 8/6/2025. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Licensee Kingston Okoro. According to the facility’s license, the facility has a maximum capacity of six (6) elderly residents age 60 and above, one (1) of whom may be non-ambulatory in bedroom #4. The facility has a hospice waiver for 5 residents. During today’s inspection, there were a total of five (5) residents in care. This facility does not feature a secured perimeter or delayed egress doors. During today’s visit, LPA observed three non-ambulatory residents in care, one (1) bedridden resident in room number #3, and an ambulatory resident in room #6, one(1) non-ambulatory Resident #2(R2) in bedroom #1, one(1) non-ambulatory Resident #3(R3) in bedroom #5, one(1) non-ambulatory resident in bedroom #4. A review of the Physician Report indicated that Resident #2(R2) and resident #3(R3) R3 are non-ambulatory and resident #1(R1) is bedridden. The facility only has clearance for one non-ambulatory resident in bedroom #4. During an annual inspection on 8/6/2025, LPA observed, and a review of the physician's report confirms, five (5) residents in care: one ambulatory, three (3) non-ambulatory, and one bedridden. LPA advised the Licensee to contact the San Diego Fire—Rescue Department (SDFRD) to learn about fire code clearance and evaluate the bedridden and non-ambulatory regulation at the time of this visit. (continued on 809-C) (continued from 809) On September 10, 2025, Per SDFRD, the facility is only allowed one non-ambulatory resident in the facility, which is in alignment with the current license. This poses an immediate safety risk to residents in care. LPA reviewed the process of submitting a new application with the updated fire clearance for one bedridden resident and five non-ambulatory residents. LPA also instructed the licensee on the 30-day eviction procedure as well as the need to update resident records accordingly. One deficiency was cited per California Code of Regulations, Title 22, for violation of the facility's fire clearance.(Refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Licensee Kingston Okoro, to whom a copy of this report, the LIC809-D, a Civil Penalty Assessment form - LIC 421IM and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Sep 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Sep 23, 2025

All facilities shall maintain a fire clearance approved by the city...or the State Fire Marshal. Prior to accepting or retaining...shall notify the licensing agency and obtain an appropriate fire clearance approved by...or the State Fire Marshal. This requirement is not met as evidenced by: Based on a records review, the licensee did not obtain an approved bedridden and non-ambulatory fire clearance for 3 out of 6 [R1],[R2], and [R3] residents, which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Sep 22, 2025

Plan of correction: The licensee stated they will issue a 30-day notice to the bedridden/non-ambulatory residents [R1],[R2],[R3] in care by the POC due date and would resubmit an application for a bedridden fire clearance/non-ambulatory by 9/6/2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to commence a Required Annual Inspection. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Dourjina Paul . LPA also discussed the purpose of the visit with licensee/Administrator Kingdley Okoro.. LPA also discussed the purpose of the visit with licensee/Administrator Kingsley Okoro During today’s visit, LPA spoke briefly to staff and residents. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. No deficiencies were cited during today’s visit. An exit interview was conducted with LIcensee/Administrator OKORO, KINGSLEY and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Amy Domingo conducted an announced Pre-Licensing and Comp III visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified herself to, and explained the purpose of the visit to applicant Administrator Kingsley Okoro. The facility fire clearance was granted on 5/24/24 and reflects that the facility is approved for one non ambulatory resident and five ambulatory resident. During today’s visit, LPA, accompanied by the applicant, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Client bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 72 degrees F. Water temperature in a client bathroom was 125 F. The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future client use. Refrigerator temperature was 34 F, and freezer temperature was 0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential client and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Per the applicant, no firearms or ammunition are or will be stored at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. 2 fire extinguishers and 2 first aid kits were present. Required licensing postings were observed in visible areas of the facility. Continue from LIC809 The items reviewed were compliant with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. Kingsley Okoro was advised that the facility’s application is pending management final review and approval. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (3/22) were left with the Director, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 25, 2024