Comfort First Home Care

Allegation investigated: Resident sustained injuries due to neglect/lack of supervision Resident wandered from the facility due to neglect/lack of supervision Facility is not maintaining resident's medication records

Licensing Program Analysts (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Administrator (ADMIN) Jenny Pham and explained the purpose of today’s visit. The investigation consisted of the following: On March 10, 2025, LPA Kim conducted a health and safety visit with ADMIN Jenny Pham. LPA obtained copies of Rental/Lease Agreements and Hospital Discharge Records of the residents. The investigation revealed the following: Allegation: Resident sustained injuries due to neglect/lack of supervision. Continued on LIC9099C Substantiated It I alleged resident #1 (R1) fell outside of the facility and sustained multiple lacerations. Based on the investigation, record review revealed that Resident 1(R1) had a rental agreement signed on December 5, 2024, with the move in date of October 23, 2024. The facility became licensed on December 13, 2024, however, R1 continued to live in the facility without admission agreement, medical records, plan of care, or appraisal records maintained at the facility. The investigation further revealed that R1 required care and supervision. One staff (S1) stated they provided care to R1 and stated although R1 was considered a tenant, R1 was sometimes confused and required care and supervision. Legacy Home Health also provided care including shower and diaper changes per Witness#1. Based on interviews conducted, Staff 1 (S1) stated that on March 4, 2025, after preparing dinner in the kitchen, S1 noticed that Resident 1 (R1) was missing from the facility. S1 stated R1 was last seen approximately one hour earlier, and S1 did not notice R1 exit the facility. There was no auditory alarm to alert staff. S1 admitted that after discovering R1 was missing, S1 did not report the incident to law enforcement or R1’s family and only notified the administrator. S2 stated per interview that they do not know if anyone looked for R1 when R1 left the facility. S2 also stated they did not document the incident. Based on record review, hospital records revealed that on March 4, 2025, at approximately 3:00 PM, Resident 1 (R1) was observed by bystanders walking barefoot in the neighborhood when R1 tripped and fell onto their right side. Abrasions were noted to the back of R1’s head, chin, right shoulder, and left foot. Bystanders contacted emergency services, and R1 was transported to the hospital for evaluation. Photographs taken at the hospital showed bruising to R1’s toes, lower extremities, right shoulder, both forearms, and the lower portion of the face near the chin. Hospital records further documented that R1’s family reported R1 had a history of hypertension, Parkinson’s disease, and confusion. R1 was diagnosed with altered mental status, abrasions, fall, syncope, and collapse. Allegation: Resident wandered from the facility due to neglect/lack of supervision. It is alleged that R1 walked out of the facility through the main gate. Based on record review, hospital records dated March 4, 2025, revealed that Resident 1 (R1) was found injured by bystanders while wandering in the neighborhood. Hospital records further documented that R1 stated they climbed over the fence and exited the facility. A police report dated March 4, 2025, indicated that Continued on LIC9099C R1 was reported as a missing adult and had been missing since approximately 3:00 PM. Additional hospital records dated March 4, 2025, documented that R1 was diagnosed with altered mental status, abrasions, fall, syncope, and collapse. The records further indicated that R1 experienced hallucinations and had a family history of schizophrenia. Based on interviews conducted, three out of three staff corroborated the allegation. S1 stated that R1 must have walked out of the facility and climbed over the fence because the gate was always locked. S2 stated that they were not at the facility at the time R1 was discovered missing; however, S2 was notified by S1 that R1 was no longer at the facility. S2 further stated that the facility was later informed by the hospital that R1 had been transported there. Staff 3 (S3) stated that they did not know much about the incident but were aware that R1 was not at the facility on the incident date. Allegation: Facility is not maintaining resident's medication records. It is alleged that facility did not have a copy of R1’s medication list when requested. Based on interviews conducted, S1 and S2 stated that they did not have a medication log for R1. S1 and S2 indicated they believed a medication log was not necessary because R1 was able to manage their own medications. Based on observations made on March 10, 2025, and March 18, 2025, LPA Kim did not observe an updated or current medication log for R1 at the facility. Based on record review, the facility has a medication list for R1 from another facility dated October 22, 2024 and there were no prescriptions available for review. Based on information gathered, the facility did not maintain R1’s medication record. Based on information gathered through interview and record review, the preponderance of evidence standard has been met, therefore, the allegations Resident sustained injuries due to neglect/lack of supervision, Resident wandered from the facility due to neglect/lack of supervision, and Facility is not maintaining resident's medication records were found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6 Chapter 8. An Immediate Civil Penalty is being assessed in the amount of $500. See the attached LIC421IM. Continued on LIC9099C It is alleged that R1’s medication had included a Vitamin B-12 that belonged to another resident. It is alleged that there is photo proof that the medication was placed in the wrong resident’s medication. Based on observations made on March 18, 2025, Licensing Program Analyst Edward Kim observed medications stored on open shelves behind the staff desk in the office. The shelves were accessible, and the office door remained open and unlocked throughout the visit. On May 7, 2025, Investigator Ge Sun also observed a medication box on a shelf in the office and noted that the office door was open and unlocked. R1’s medications were not observed during either visit because R1 did not return to the facility after being hospitalized. During the investigation, the Department reviewed a photograph showing R1’s medications on a couch alongside R2’s Vitamin B-12. However, there was no clear evidence that the medications were stored together improperly, as they may have been temporarily placed there during the sorting process. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegation Staff mismanaged resident's medication. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of the report was provided to Administrator Jenny Pham. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). An exit interview was conducted, and a copy of this report and the appeal rights were provided to Administrator Jenny Pham.the state’s words, verbatim · CDSS document, May 26, 2026 · control 22-AS-20250305152012

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 27, 2026

87464(f)(1)Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above. Facility staff did not provide appropriate care and supervision to R1 which resulted in R1 sustaining serious injuries while wandering around the neighborhood. This poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Licensee will provide training to all staff regarding proper care and supervision of all residents. Licensee stated they will send proof of all corrections to CCLD via email to edward.kim@dss.ca.gov by POC due date May 27, 2026. *Civil Penalty Assessed"

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87461(a)(1) · Plan of correction due date: May 27, 2026

87461 Mental Condition (a)The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (1) tends to wander; This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above. Facility staff did not provide appropriate care to monitor R1 which resulted in R1 wandering from the facility undetected This posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Licensee stated they will assess all residents and create a plan of care and will send proof of correction to CCLD via email to Edward.kim@dss.ca.gov by POC due date May 27, 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jun 5, 2026

87465 (a)A plan for incidental medical and dental care shall be developed by each facility... (6)When requested by the Department, a record... of ... medication shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above. Facility staff did not maintain the resident #1’s medication records as needed. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Licensee stated they will ensure all medical records for all residents such as Medication Administration Record, Centrally Stored Medical Destruction Record, and other necessary documents. Licensee will train all staff and sent a copy of the training and all participants who attended with signature to CCLD via email to edward.kim@dss.ca.gov by POC Due date June 5, 2026.

Type of visit: Case Management - Deficiencies

On May 26, 2026, ,Licensing Program Analyst (LPA) Edward Kim conducted a case management- deficiency visit unrelated to a complaint investigation (Complaint# 22-AS-20250305152012). LPA observed the facility did not send an incident report with R1 wandering away from the facility and going to the hospital on March 4, 2025. A deficiency was cited during the inspection visit according the California Code of Regulations Title 22 Division 6 Chapter 8. Facility An exit interview was conducted, and a copy of this report and the appeal rights were provided to Administrator Jenny Pham.the state’s words, verbatim · CDSS document, May 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 5, 2026

87211 Reporting Requirements (a (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. This requirement is not met evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above. Facility did not notify the department of the incident within seven days of occurrence. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Licensee stated they will send a copy of the Incident report and send copy of an agreement that they read, understood, and signed to follow the regulation CCR 87211(a)(1) to CCLD via email to edward.kim@dss.ca.gov by POC due date June 5, 2025.

Type of visit: POC

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a plan of correction visit for deficiencies issued on December 9,2025. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Jenny Pham and discussed the purpose of the visit. LPA toured the facility and observed that the rodent droppings have been cleaned and new traps have been set. LPA observed a Terminix pest report dated December 10, 2025, where a Terminix service technician made a visit to the facility and treated areas where droppings were found. Thus clearing deficiency 87555(b)(27). AD will schedule a follow up visit in January with Terminix and send to LPA by COB Monday December 15, 2025. LPA observed a fire drill in service training that was conducted on December 10, 2025 with facility staff. Thus clearing deficiency 1569.695(c). LPA observed a medication policy created by AD and an in service conducted on said policy on December 12, 2025, with facility staff. Thus clearing deficiency 87465(c)(2). LPA observed a completed physicians report for Resident #1 and a TB test dated December 11, 2025. Thus clearing deficiency 87458(a). Based on today's observations all citations given on December 9, 2025, have been cleared. An exit interview was conducted and a copy of this report along with clearance letters were left at the facility.the state’s words, verbatim · CDSS document, Dec 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Jenny Pham and discussed the purpose of the visit. The facility is a single story home with two caregiver rooms, three resident bedrooms, one tenant bedroom, staff office, five bathrooms, living room, kitchen, dining room, and attached two car garage. LPA observed the resident bedrooms and observed that they had the required components and furnishings. LPA observed the bathroom off the main hallway to have rodent droppings in one of the empty drawers. LPA tested the water to be between 105.8 and 115.8 degrees Fahrenheit in the facility restrooms. LPA observed the restrooms to have toilet paper and textured flooring in the showers. LPA observed the kitchen to have rodent droppings and traps set. LPA observed the knives to be in a locked drawer at the end of the counter. LPA observed the appliances to be operational. LPA observed a two day perishable and seven day nonperishable food supply on hand. LPA observed the toxins and chemicals to be locked and made inaccessible to residents in the closet by the front door. LPA observed the staff office to be locked and made inaccessible to residents. LPA observed the centrally stored medication to be locked in the staff office and made inaccessible to residents in care. LPA observed a clean supply of linens in the hall cupboard for resident use. LPA observed the front and back yard to have a shaded seating area for resident use. LPA observed no debris and obstructions on the facility grounds. LPA observed a tenant renting a room in room 4. The tenant is background cleared and associated to the facility. Continue on LIC809-C LPA reviewed staff files and no discrepancies were observed. LPA reviewed resident files and 3 of 3 residents do not have a completed needs and services plan and 1 of 3 residents do not have a medical assessment with a tb test on file. LPA observed resident medications and 2 of 3 residents had a lapse in medication due to facility staff not refilling their prescriptions before they had run out causing the medication to not be given as prescribed. LPA observed the emergency disaster plan has not been filled out in its entirety. LPA did not observe an emergency disaster drill. All staff are background cleared and associated to the facility. LPA informed AD that the annual fees are due and provided the PIN number at the time of the inspection. Based on today’s observations technical violations and deficiencies are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD and a copy of this report along with technical violations, LIC809C, LIC 809D, LIC 858, LIC859 and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Dec 9, 2025

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On March 18, 2025, at 9:50 AM, Licensing Program Analyst (LPA) Edward Kim conducted a case management- deficiency visit unrelated to a complaint investigation (Complaint# 22-AS-20250305152012). On March 10, 2025, during a complaint visit, LPA observed the following deficiencies: 1. S3 is working in the facility without background clearance. 2. Two individuals who were identified as friends of S3 slept in the facility from March 7, 2025, through March 10, 202,5 without background clearance. 3. The facility is not maintaining records for all residents. 4. The facility is not maintaining records for all staff. Deficiencies were cited during the inspection visit according the California Code of Regulations Title 22 Division 6 Chapter 8. A civil penalty was assessed at this visit. An exit interview was conducted, and a copy of this report and the appeal rights were provided to Administrator Minh Pham.the state’s words, verbatim · CDSS document, Mar 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 19, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working, residing, or volunteering in a licensed facility: 2) Obtain a California clearance or a criminal record exemption... This requirement is not met as evidence by: Based on observation, record review, and interviews, the licensee did not comply with the section cited above. LPA Kim observed S1 working, and two visitors resided in the facility not having background clearance. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: Licensee states they will have background clearance on S3 before they are allowed back on the facility. Licensee will send proof of completion background clearance and association to CCLD through email to edward.kim@dss.ca.gov by POC due date March 18, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: HSC87412(a) · Plan of correction due date: Apr 1, 2025

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. This requirement is not met as evidence by: Based on observation, interviews, and record review, the Licensee did not comply with the section cited above. LPA Kim observed personnel records of S1-S3 were missing LIC503, LIC501, and training hours. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: Licensee states they will provide LIC501, LIC503, and training hours for S1-S3 to CCLD through email to edward.kim@dss.ca.gov by POC due date April 1, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Apr 1, 2025

87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...readily available to facility staff and to licensing agency staff. This requirement is not met as evidence by: Based on observation, interviews, and record review, the Licensee did not comply with the section cited above. LPA Kim observed individuals R1-R6 did not have residents with admissions agreement, physician’s report, pre-appraisal, and other pertinent documents.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: Licensee states they will maintain records for the indviduals at the facilty with physician's report, pre-appraisal, LIC621, consent forms, and LIC613C and send proof to CCLD via email to edward.kim@dss.ca.gov by POC due date April 1, 2025.

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Rose Ruppert and Fred Arias made an announced visit to the facility at 8:00 AM for the purpose of conducting a pre-licensing inspection. LPAs met with Administrator (AD) Minh Pham. An application to operate a Residential Care Facility for the Elderly (RCFE) for a capacity of six residents with five non-ambulatory and one ambulatory was received on April 3, 2024. There are no residents in care. The facility is a six bedroom, five bathroom single-story building. The six residents will occupy three shared bedrooms in the rear of the home. LPAs observed there were no auditory alarms on the non-ambulatory room exits but each bedroom had a call button by the entry doors. Two additional bedrooms are occupied by others: one caretaker who is background cleared and a renter who is not. Administrator will work on background clearance for the renter who lives on the property. There is an additional empty bedroom with three beds that will not be used for residents or staff at this time. The facility eventually plans to expand their capacity with a new fire clearance in the future. All bedrooms had the required furnishings and bathrooms all had grab bars and tight fitting closed trash cans. During today’s visit, LPAs toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and testing hot water temperatures in four of four resident bathrooms. The hot water temperature measured between 112.8 and 119.1 degrees Fahrenheit and all smoke and carbon monoxide detectors were operational and are interconnected throughout the facility. The fire extinguishers are charged but no service dates were attached. AD will get fire extinguishers serviced. The living room fireplace does not have a screen and AD will purchase a screen. LPAs inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPAs observed sharps were not secured so AD will install locks to secure knives in the kitchen. All cleaning supplies were secured in a locked closet. (Continued on LIC 809-C) (Continued from LIC 809) LPAs observed the "See Something, Say Something" PUB 475 poster was prominently posted and is the required size. The Emergency Disaster plan, facility sketch, Theft and Loss, Personal Rights and Resident Councils documents were posted in the entry way. LPAs observed the First Aid Kit had all the required elements and a First Aid manual. AD will purchase additional water bottles for Emergencies. While touring the exterior LPAs noted there was not a shaded seating area for residents. AD mentioned he would create a shaded area. LPAs noted there are no exterior backyard gates and the AD disclosed that the property is gated and the entry gate will always be closed and that there is a call button at the entry gate. LPAs confirmed that administrator has a current administrator certificate which expires on June 24, 2026. LPAs conducted the Component Three Orientation with AD. AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento after repairs and corrections are completed. AD will notify LPAs when corrections are completed. An exit interview was conducted and a copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Nov 15, 2024

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Rose Ruppert and Fred Arias returned to the facility to complete a pre-licensing visit, from this morning, that required corrections in order to meet licensing requirements. LPAs were greeted and granted entry by Administrator, Minh Pham at 4:25 PM. Administrator and LPAs toured the facility and observed the following items corrected from this morning's visit. Two non-ambulatory bedrooms will have auditory alarms installed on exit doors, as well as an exterior door in the hallway next to resident rooms and the main sliding glass door from the indoors to exterior. Administrator was installing alarms at time of this report. A shaded canopy was placed over the seating area in the patio to provide shade. Two fire extinguishers were inspected by Fire Prevention Services after LPAs left this morning and are fully charged as of November 15, 2024. Administrator created a locked drawer for sharps and secured the knives and oven knobs in the locked drawer. A screen for the living room fireplace was purchased. Six gallon jugs of water were purchased for emergencies. Administrator reached out to the Centralized Applications Bureau (CAB) Analyst regarding obtaining background clearance for the renter who lives on the property. LPAs verified all corrections were made and AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Nov 15, 2024

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 Method: Telephone call with CAB COMP II Participants: Mihn Pham, Administrator/Owner; Shannon Betker, analyst. Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Oct 15, 2024