Comfort Home 2

Allegation investigated: Facility has mold.

On04/08/2026, Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to initiate and deliver findings on the allegation listed above. LPA was greeted by Facility Staff Anayeli Hoyos and granted entry to the facility and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First Allegation:-Facility has mold. During a facility walk-through conducted by Licensing Program Analyst (LPA) Singh, no evidence of mold was observed on walls or within any interior areas, including the kitchen and hallways. This finding was supported by interviews with two staff members and four residents, Two(2) out of two (2) staff and four(4) out of four(4) residents, all of whom reported no sightings of mold or unusual odors on the premises. While the licensee has proactively replaced the kitchen sink countertop and is currently renovating a resident bathroom, an inspection of a recently replaced bedroom ceiling, revealed no signs of water intrusion, mold growth, or unusual odors. Unsubstantiated Based on the evidence found during the investigation, the allegation listed facility has mold is deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed, signed and provided to Staff/Caregiver Anayeli Hoyos facility representative at the conclusion of this visit.the state’s words, verbatim · CDSS document, Apr 8, 2026 · control 56-AS-20260401171111

Type of visit: Required - 1 Year

On 03/27/2025 at 0AM, Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Singh met with Staff-Irma and Anayeli Hoyos and was granted entry to the facility. At the time of the visit there were two (2) staff present, and (5) residents present, one resident was out in the community. The facility is a five (5) bedroom, two and a half (2 1/2) bathrooms with a kitchen/dining area and living room and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) of which two (2) can be ambulatory residents and four (4) can be non-ambulatory residents. The facility's approved for two (2) hospice waivers. The current census is six (6) residents. LPA was accompanied by Staff-Anayeli Hoyos to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in a resident shared bathrooms were to be at 122 degrees Fahrenheit. Deficiency will be issued. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Three (3) fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** Cleaning supplies and sharps were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine cabinet with the resident’s medications locked. LPA observed the complete first aid kit and first aid book at the facility. Also, during the tour of the facility, LPA observed side fence gate unlocked. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Emergency water was observed but there is no emergency food for the residents. Deficiency will be issued. Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has enough staff to provide care and supervision to the residents in care. Record Review: LPA Singhobserved no current fire drill or earthquake drill conducted at the facility. Deficiency will be issued. LPA reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed three (3) residents file reviewed Pre-placement Appraisals and Needs and Services Plan. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings with tuberculosis (TB) test result. records review was completed, no issues. Medications/Medication Administration Record (MAR) were audited, and LPA observed no issue. Liability Insurance is valid through LPA Singh observed that the facility does not have updated liability insurance for current year and has been expired. Deficiency will be issued. Based on the observations made during today’s visit, deficiencies were issued per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted with Staff Anayeli Hoyos and provided a copy of this report LIC 809, 809C, 809D and appeal rights to Licensee Sushma Lal via email.the state’s words, verbatim · CDSS document, Mar 5, 2026

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Illegal Eviction. Regarding the allegation “Illegal Eviction” LPA conducted an interview with Staff #1 who informed LPA that Resident #1 was no longer living at the facility. Staff #1 further explained that facility was no longer able to meet R#1 care needs as R#1 had a change in condition and due to that reason as of 4/24/2025 R#1 was evicted. During record review pertaining to R#1 LPA discovered that an eviction notice was not on file. LPA asked Staff #1 for the eviction notice and LPA was informed that a notice was not provided to the resident or R#1 responsible party. Staff #1 further explained that the eviction process was discussed verbally with R#1 POA, the facility administrator and R#1 social worker. Substantiated Throughout the review of records and observation it was discovered that the facility did not provide resident (R#1) or resident’s responsible party a written eviction notice discussing the reason of the eviction in addition, the facility did not seek licensing approval for the eviction. Based on the evidence gathered during the investigation, the above allegation is Substantiated. Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Eviction Procedures 87224(a)(2) from division 6, chapter, article 6, is being cited on the attached LIC 9099 D. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights to Facility Administrator. Second allegation: Staff use chemical restraint on residents in care. Regarding the allegation stated above LPA conducted a review of record pertaining to R#1 LPA observed medication that all medication pertaining to R#1 was prescribed by R#1 health provider in addition, LPA observed that medication that was prescribed to R#1 was being administered based on medication orders. LPA conducted interviews with Residents #2-6 regarding the allegation stated above and Resident #3 Resident #4 and Resident #5, informed LPA that staff administer their medication based on medication orders. Furthermore, Resident #3 Resident #4 and Resident #5, stated that they have not witnessed staff to over medicate residents or utilize medication as a chemical restraint. All residents informed LPA of feeling safe and not having any issues or concerns. LPA conducted interviews with staff regarding the allegation stated above and Staff #1 and Staff #2 informed LPA that all medication that is administered to the resident is given based on the medication orders. Staff #1 and Staff #2 informed LPA that they have not witness staff to use chemical restraint on residents in care. In addition, Staff #1 and Staff #2 also informed LPA that they have not witness any staff to over medicate a resident[s] in care. Third allegation: Staff does not ensure needs assessment plans are documented for residents in care. Regarding the allegation stated above LPA requested documentation pertaining to R#1 during the review of records LPA discovered that R#1 assessment plan were on file. During the review of records LPA also discovered that all documentation pertaining to needs and care for R#1 was on file. LPA conducted a file review and observed that 6 out of 6 residents files were complete and all files obtained an individual care plan along with the needs and services for each resident in care. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Caregiver Anayeli Hoyos at the end of the visit.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 56-AS-20250425114731

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(2) · Plan of correction due date: Aug 22, 2025

Eviction Procedures...(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility or to an independent living arrangement as a result of the forfeiture of a license.... (2) Provide each resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction. The notice shall include all of the following. This requirement is not met as evidence by: Based on observation, and record review, the licensee did not ensure to follow eviction procedures for 1 out of 1 resident, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: The licensee has agreed to read over the "Eviction Procedures" regulation and provide a written statement that indicates the acknowledgement after the review of the regulation. The acknowledgement shall be reviewed and signed by all facility staff associated to the facility. The licensee will send the acknowledgement to LPA via email on 8/22/2025.

Type of visit: Required - 1 Year

On 03/27/2025 at 08:45 AM, Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Singh met with a staff and was granted entry to the facility. Licensee Sushma Lal was contacted and arrived at the facility during the visit. At the time of the visit there were two (2) staff present, and five (5) residents present. The facility is a five (5) bedroom, two and a half (2 1/2) bathrooms with a kitchen/dining area and living room and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) of which two (2) can be ambulatory residents and four (4) can be non-ambulatory residents. The facility's approved for two (2) hospice waivers. The current census is five (5) residents. LPA was accompanied by Staff #1 (S1) to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in a resident shared bathroom to be at 116-degree Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Three (3) fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** Cleaning supplies and sharps were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine cabinet with the resident’s medications locked. LPA observed the complete first aid kit and first aid book at the facility. Also, during the tour of the facility, LPA observed side fence gate unlocked. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has enough staff to provide care and supervision to the residents in care. Record Review: LPA observed that the facility does have updated liability insurance dated/effective-5/1/2024-5/1/2025. Also, LPA observed no current fire drill or earthquake drill conducted at the facility. Deficiency will be issued. LPA reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed three (3) residents file reviewed do not have the required Pre-placement Appraisals and Needs and Services Plan. Deficiencies will be issued. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings with tuberculosis (TB) test result. Medications/Medication Administration Record (MAR) were audited, and LPA observed no issue. Based on the observations made during today’s visit, deficiencies were issued per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC809D, and Appeal Rights were discussed and provided to Licensee Sushma Lal.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Case Management - Other

On 03/06/2024 at 11:30 AM, Licensing Program Analysts (LPAs) Melody Brown and Paola Guerrero made an announced visit to the facility to amend the form LIC809D issued on 02/28/2024 due to computer error. LPA Brown met with a staff and was granted entry to the facility. Licensee Sushma Lal was contacted and informed of the visit. At the time of the visit there's (1) staff present, and five (5) residents present. During this visit, LPA Brown amended the form LIC809D issued on 02/28/2024 due to computer error and issued a new form LIC809D for Postural Supports 87608(a)(3) as Resident #1 (R1), Resident #3 (R3) and Resident #5 (R5) have half bed rails without their physician order indicating the need for half bed rail for mobility. Also, a civil penalty of $250.00 will be assessed as the facility was cited for the same violation within 12-months period. An exit interview was conducted, and this report (LIC809), LIC809D, and Appeal Rights were discussed and provided to Licensee Sushma Lal.the state’s words, verbatim · CDSS document, Mar 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Mar 15, 2024

87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency... 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 by allowing Resident #1 (R1), Resident #3 (R3) and Resident #5 (R5) have half bed rails without their physician order indicating the need for half bed rail for mobility in their facility file which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Licensee stated to obtain doctor's written order indicating the need for half bed rail for R1, R3 and R5 and submit proof to LPA Brown at Plan of Correction (POC) due date.

Type of visit: Required - 1 Year

On 02/28/2024 at 09:30 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Licensee Sushma Lal was contacted and arrived at the facility during the visit. At the time of the visit there's (1) staff present, and five (5) residents present. The facility is a five (5) bedroom, two and a half (2 1/2) bathrooms with a kitchen/dining area, and living room and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) of which two (2) can be ambulatory residents and four (4) can be non-ambulatory residents. The facility's approved for two (2) hospice waivers. The current census is five (5) residents. LPA Brown was accompanied by Staff #2 (S2) to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in a resident shared bathroom to be at 143 degree Fahrenheit. Deficiency will be issued. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Three (3) fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** Cleaning supplies and sharps were kept inaccessible to residents in care. However, LPA Brown observed Staff #2 (S2) two (2) bottles of medication in the kitchen drawer, not locked and accessible to residents in care. Also, during the tour of the facility, LPA Brown observed plant fertilizer at the backyard, not locked and accessible to residents in care. Deficiency will be issued. Moreover, LPA Brown observed all residents medication for the day were pre-poured in a small container up to bedtime. Deficiency will be issued. There was a designated storage space for resident/staff files. There is a Medicine cabinet with the resident’s medications locked. LPA Brown observed the complete first aid kit and first aid book at the facility. Also, during the tour of the facility, LPA Brown observed side fence gate locked with a padlock. Deficiency will be issued. To add to that, LPA Brown observed screen door in disrepair. Deficiency will be issued. LPA Brown also observed Resident #1 (R1), Resident #3 (R3) and Resident #5 (R5) with half bed rails and no written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA Brown observed that the facility does not have updated liability insurance. Deficiency will be issued. Also, LPA Brown observed the facility not having the required Infection Control Plan. Deficiency will be issued. Moreover, LPA Brown observed no current fire drill or earthquake drill conducted at the facility. Deficiency will be issued. LPA Brown reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Brown observed three (3) residents file reviewed do not have the required Pre-placement Appraisals and Needs and Services Plan. Deficiencies will be issued. LPA Brown reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed that Staff #5 (S5) does have criminal background clearance but the facility did not transfer S5 criminal background clearance to the facility. Deficiency will be issued. Also, during this visit, a civil penalty of $500.00 will be issued for not transferring S5 criminal record clearance to the facility. ***Continuation in LIC809C *** Medications/Medication Administration Record (MAR) were audited, and LPA Brown observed no issue. Per LPA Brown's review, the facility were cited for the same violation on 11/17/2023 for CCR 87608(a)(5)(A) Postural Supports and CCR 87705(l)(2) Care of Persons with Dementia. During this visit, a civil penalty of $250.00 per regulation for repeating the same violation within 12 months will be issued. Based on the observations made during today’s visit, deficiencies were issued per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102 and Appeal Rights were discussed and provided to Licensee Sushma Lal.the state’s words, verbatim · CDSS document, Feb 28, 2024

Allegation investigated: Staff did not protect resident from being hit by another staff.

On 11/17/2023 at 01:40 PM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to investigate and deliver findings for the allegation listed above. LPA Brown was greeted and granted entry by a staff member and Licensee Sue Lal was contacted and informed of the visit. LPA Brown explained the purpose of the visit to Licensee Lal. The investigation consisted of observation, interviews, and a review of pertinent documentation. The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The allegation indicates that Staff did not protect resident from being hit by another staff. LPA Brown did not find evidence to corroborate the allegation. Interviews with five (5) of five (5) residents indicated that they did not witness a staff or a Home Health Nurse hit Resident #1 (R1) and there’s no incident that happened at the facility that a staff or a Home Health nurse hit a resident. Interviews with three (3) of three (3) staffs revealed they never witness a staff or a Home Health nurse hit R1 or any resident at the facility. ***Continuation in LIC9099C*** Unsubstantiated Staffs #1 (S1), Staffs #2 (S2) and Staff #3 (S3) reported that they were not supervising the Home Health Nurse when they are at the facility to provide care and supervision to R1 but they are available for assistance if needed. S1, S2 and S3 denied witnessing Home Health Nurse hit R1 or any resident at the facility. Home Health Nurse reported to LPA Brown that they never hit R1 and no incident happened at the facility that a Home Health staff hit R1. Based on interviews and records review, the allegation Staff did not protect resident from being hit by another staff is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, where this report (LIC9099) was discussed and provided to Licensee Sue Lal.the state’s words, verbatim · CDSS document, Nov 17, 2023 · control 56-AS-20231026145308

Type of visit: Case Management - Deficiencies

On 11/17/2023 at 01:40 PM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to initiate a Case Management visit. LPA Brown was greeted and granted entry by a staff member and Licensee Sue Lal was contacted and informed of the visit. LPA Brown explained the purpose of the visit to Licensee Lal. The investigation consisted of observation, interviews, and a review of pertinent documentation. On 11/17/2023 at 02:00 PM, LPA Brown toured the facility with Staff #2 (S2) and observed the side gate secured and locked with padlock. LPA Brown informed Licensee Sue Lal that deficiency will be issued as they did not comply with the regulation by locking the side gate/perimeter fence gate in a manner that residents are unable to exit without assistance. This poses an immediate health, safety, and personal rights risk to residents in care. Moreover, during the tour of the facility on 11/17/2023, LPA Brown observed the half bed rails on Resident #3 (R3) and no written order from R3's physician indicating the need for the postural support maintained in R3 facility record. LPA Brown informed Licensee Lal that deficiency will be issued as this poses potential health, and safety risk to residents in care. An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and provided to Licensee Sue Lal.the state’s words, verbatim · CDSS document, Nov 17, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(I)(2) · Plan of correction due date: Nov 18, 2023

87705 Care of Persons with Dementia: (I) The following initial and continuing requirements shall be met by the licensee to lock the exterior doors or perimeter fence gates: (2) The Licensee shall ensure that the Fire Clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by: Based on observation,interview and records review, the Licensee did not comply with the regulation by locking the side gate/perimeter fence gate in a manner that residents are unable to exit without assistance. This poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 17, 2023

Plan of correction: The licensee agrees to remove the lock and agree to not lock the perimeter fence gate without Licensing and Fire Marshall approval. Caregiver unlocked gate during visit. Plan of Correction (POC) cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Dec 4, 2023

87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency... This requirement is not met as evidenced by: Based on observation, interview andr ecord review, the licensee did not comply with the section cited above by having Resident #3 (R3) half bed rail with no written order from R3's physician indicating the need for the postural support maintained in R3 facility record which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 17, 2023

Plan of correction: The Licensee stated to submit written order from R3's physician indicating the need for the postural support and submit letter to Community Care Licensing Division (CCLD) requesting approval for R3 half bedrail at the facility by Plan of Correction (POC) due date.