Comfort Home for Elderly

Allegation investigated: Staff did not ensure the fire alarms were working property.

On 08/07/2025, Licensing Program Analyst (LPA) Antonine Richard conducted an initial 10-day complaint visit to facility and deliver findings. LPA was granted access and allowed to enter the facility to conduct the inspection. LPA Richard was met by staff Nelly Salvador, and the purpose of today’s visit was explained. Later was joined by the Administrator Socorro Trinidad. Investigation consisted of the following: On 08/07/2025, LPA requested and obtained the staff roster, resident roster, and duty logs of Staff to determine which staff members were at the facility during the time the fire alarms didn’t set off, and the Facility Plan of Operation. LPA interviewed the Administrator #1 (A1) and Staff #1 (S1). LPA toured the facility. Report Continued on LIC9099-C Unsubstantiated Allegation: Staff did not ensure the fire alarms were working properly. The complaint alleges that the fire alarms were unplugged; if there had been a fire, the fire alarms would not have sounded. On August 7, 2025, at 9:45 a.m., LPA Richard interviewed Administrator #1 (A1), who stated that on June 25, 2025, one of the residents passed away at the facility. The staff were busy dealing with the resident's passing, and one of the caregivers left a bagel in the microwave that burnt, causing the whole kitchen and living room to smell burnt. There was no fire or smoke to trigger the alarms. On August 7, 2025, LPA interviewed staff member #1 (S1), who reported that there was no smoke, only the smell of a burning bagel. At 10:00 AM on the same day, LPA Richard toured the facility and noted that there were eight smoke detectors, and that the fire alarm system was combined into one system and in operable condition. At 10:30 AM, LPA tested all eight smoke and fire alarms, finding that they all functioned properly. LPA also observed that the fire alarms are electric and not plugged in, with the exception of the carbon monoxide alarm. Based on observation and interviews conducted, there is insufficient evidence to support the allegation: Staff did not ensure the fire alarms were working properly. 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; therefore, the allegation is Unsubstantiated. There were no deficiencies cited on today's visit. An exit interview was conducted. A copy of this report was provided to the Administrator, Socorro Trinidad.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 11-AS-20250730132939

Type of visit: Required - 1 Year

On 07/21/2025 at 11:45 am Licensing Program Analyst (LPA), Bernadette Allen conducted an unannounced visit to conduct the annual inspection. Upon arrival to the facility, LPA Allen met with Jusus Rodriguez support staff who was informed of the purpose of the visit and allowed LPA into the facility. Jesus called Socorro Trinidad Administrator and informed her of the purpose of today’s visit who arrived about 12:05 PM. The facility is licensed to serve (6) residents ages 60 and above, of which (5) may be non-ambulatory and (1) bedridden. Facility has an approved hospice waiver for (4) residents. The facility is in a residential neighborhood that consists of 5 bedrooms, 2 bathrooms, living room, dining room, kitchen and the washer & dryer are in hallway . At 12:15 AM, LPA Allen, toured the physical plant with Socorro Trinidad- Administrator. There were no bodies of water or obstructions on the premises. There is a shaded area for the residents, visitors, and staff. LPA Allen observed the 5 bedrooms to have the required furniture, bedding, adequate lighting, and storage for the president’s personal belongings was observed. The bathrooms were observed to be clean, sanitary with wash basins and toilets to be in operable condition. LPA observed the fire extinguishers fully charge and smoke and carbon monoxide combo are in operable conditions. The water temperature properly measured between 105°-120°F. LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. The kitchen was inspected, and LPA observed a 5-day supply of perishable and 7-day supply of non-perishable food available and maintained properly. At 1:15 PM, LPA Allen reviewed four (4) residents files for admission agreements, updated physician reports, and needs and services plans which were up to date. LPA Allen also observed the residents Medication Administration Records (MARS) which appears that the residents are given their medications as prescribed by their physicians. LPA Allen reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings which were all current. An exit interview was conducted where this report was discussed and provided to Socorro Trinidad Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 21, 2025

Allegation investigated: .Staff did not administer resident's medication as prescribed 2.Staff did not inform the resident's authorized representatives of the resident's change in health condition

On 10/25/2024 the Department conducted a subsequent complaint visit to the facility to deliver findings for the allegations listed above. The Department was met by Socorro Trinidad, Administrator and the purpose of today’s visit was explained. The Department was granted access and allowed to enter the facility to conduct the inspection. Investigation consisted of the following: CONTINUE TO LIC9099C Unsubstantiated On 07/18/2024 the Department interviewed Staff #1- Staff# 3 (S1-S3), and reviewed records of resident #1- resident #3 (R1-R3). On 07/18/2024 the Department interviewed witness #1 (W1). The Department requested to the following documents: the Medication Administration Records (MARs), physician's orders of prescriptions, progress notes, health assessments, and any documentation of changes in health condition and incident reports related to Resident #1- Resident #3 (R1-R3). The department requested any communication logs or records, facility's policies and procedures related to medication administration, and training records for S1-S3. Investigation Revealed the Following: Allegation: Staff did not administer resident's medication as prescribed It is alleged that on 7/8/2024 R1 did not receive their PRN medication. On 07/18/2024 the department interviewed Socorro Trinidad, facility administrator. The department asked if staff did not administer resident's medication as prescribed. The Administrator stated there were no concerns or issues with staff administering resident's medication as prescribed. On 07/18/2024 the department interviewed staff #1- staff #3 (S1-S3) who were asked if staff did not administer resident's medication as prescribed. Of those interviewed S1-S3 stated there were no concerns about staff administering resident's medication as prescribed. On 07/18/2024 the department interviewed witness #1 (W1), who was asked if staff did not administer resident's medication as prescribed. Witness #1 (W1) stated there were no concerns about staff administering resident's medication as prescribed. On 07/18/2024 and 10/22/2024 the department conducted reviews of facility records. Per physicians’ orders from Roze Hospice, R1 was prescribed Morphine Sulfate (Concentrate) to be administered orally at a dose of 5 MG every 4 hours as needed for severe pain or shortness of breath. On 07/18/2024 and 10/22/2024 the department reviewed facility notes, which state a discontinuation of previous medication orders for morphine to be started on 7/7/2024, orders given o the facility at 12:45pm and an accompanying prescription issued on 7/8/2024 written at 12:49PM. CONTINUE REPORT TO LIC9099C Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not administer resident's medication as prescribed. 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, therefore the allegation is Unsubstantiated. Allegation: Staff did not inform the resident's authorized representatives of the resident's change in health condition On 07/18/2024 the department interviewed Socorro Trinidad, Administrator who was asked if staff did not inform the resident's authorized representatives of the resident's change in health condition. The Administrator stated there were no concerns or issues with staff not informing the resident's authorized representatives of the resident's change in health condition. On 07/18/2024 the department interviewed staff #1- staff #3 (S1-S3) who was asked if staff did not inform the resident's authorized representatives of the resident's change in health condition. Of those interviewed S1-S3 stated there were no concerns about staff did not informing the resident's authorized representatives of the resident's change in health condition. On 07/18/2024 the Department interviewed witness #1 (W1) who verified W1 is to be contacted for resident. W1 reported the facility staff provided updates and condition changes of resident’s condition to the authorized representative. On 10/22/2024 the department reviewed facility records and confirmed authorized representative for residents. Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not inform the resident's authorized representatives of the resident's change in health condition. 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, therefore the allegation is Unsubstantiated. There were deficiencies cited on today's visit. Exit interview conducted. A copy of the report was given to Socorro Trinidad, Administrator. .the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 11-AS-20240708130938

Type of visit: Required - 1 Year

On 08/08/2024 at 1:00 pm Licensing Program Analyst (LPA), David España conducted an unannounced annual visit using the full CAREs tool. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection. LPA was met by Socorro Trinidad Administrator and the purpose of today’s visit was explained. The facility is licensed to serve (6) residents ages 60 and above of which (5) may be non-ambulatory and (1) bedridden. Facility has an approved hospice waiver for (4) residents. The facility is located in a residential neighborhood it consists of 5 bedrooms, 2 bathrooms, living room, dining room, kitchen and washer and dryer in hallway closet and patios with shaded areas. LPA toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (5) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LIC809-C (cont). LPA inspected rooms: #1, #2, #3 #4 and #5 and smoke and carbon monoxide combo are all operable conditions. The water temperature properly measured between 105°-120°F. LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of (5) residents' service files, (2) staff personnel files and (2) Medication Administration Records (MAR) were checked. First AID kit was checked. LPA observed the facility's infection control practices. Licensee will email copy of liability insurance to LPA. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Socorro Trinidad Administrator.the state’s words, verbatim · CDSS document, Aug 8, 2024

Allegation investigated: Uncleared staff working in facility. Unqualified staff providing care to residents.

On 07/25/24, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint visit. Upon arrival at the facility LPA called the facility. LPA was granted access and allowed to enter the facility to conduct the inspection. Later on, LPA was joined by the administrator Socorro Trinidad. LPA explained the purpose of today's visit. The investigation consisted of the following: LPA interviewed staff #1-#3 (S1-S3) and residents #1-#2 (R1-R2). LPA asked questions relevant to the nature of the complaint. A toured the facility inside to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. LPA requested, reviewed, and collected Personnel Records for four Staff (4) members (S1-S4). Evaluation Report continues LIC 9099 Unsubstantiated Allegation: Uncleared staff working in the facility. The details of the complaint reported that staff employed at this facility do not have background clearance and are not cleared to work. The complainant stated there are undocumented staff that are working at the facility without US Citizenship. LPA Richard reviewed and audited personnel records for the staff #1-#4 (S1-S4), revealing that 4 out of 4 staff members have a Community Care Licensing (CCL) Criminal Background Clearance on file at the facility. On 07/23/2024, LPA ran a Facility Personnel Report Summary LIS-536 or California Department of Social Services (CDSS). The report showed all the staff were cleared. LPA interviewed the licensee (S1). Licensee stated that all the staff she hired were from referral; however, she ensured all the staff criminal backgrounds were done entirely before hiring them. Based on the information gathered, the allegation listed above is not supported. Based on record reviews and interviews, there is insufficient evidence to support the allegation that uncleared staff working at the facility. Although the allegation may have happened or is valid, there’s not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Continued LIC9099-C page 2 Allegation: Unqualified staff providing care to the residents. The details of the complaint stated that unqualified staff are providing care to the residents. The complainant reported that the staff doesn't know CPR. Interviews conducted with three staff (S1-S3) members revealed that 3 out of 3 staff members have completed all the required medical training to help take care of the residents. The records reviewed on 07/25/2024 showed that the staff had a copy of the CPR/AED First Aid Certificate and forty hours of training on file. LPA verified training certificates and training logs were up to date. Interviews with two residents #1-#2 (R1-R2) 2 out of 2 stated that they do not have any concerns of the care or supervision the staff provided to them. Due to their health condition, (R3-R4) were not interviewed. Based on the gathered information, the allegation mentioned above is not supported. Based on interviewed and records reviewed, there is insufficient evidence to support the allegation that unqualified staff providing care to residents. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated. An exit interview conducted with Socorro Trinidad and copy of the report provided.the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 11-AS-20240718153153

Allegation investigated: Staff neglect resulted in a resident sustaining multiple pressure injuries while in care Resident sustained an unexplained fracture while in care Staff did not follow a resident's dietary restrictions Facility admitted a resident that needed a higher level of care

This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 2/2/24. On 2/2/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Iris L. Cortes, Caregiver, and explained the purpose of the visit is to deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 10/3/2023 LPA Felisa Shirley and LPM Stephanie Cifuentes requested and received copies of the following records: Staff Roster, Resident Rosters for the past 2 years, admissions agreements, identification and emergency information, physician’s report, medications, death report, and hospice records for Resident 1 and Resident 2(R1-R2). Follow-up interviews were conducted by LPA Shirley with Staff 3-Staff 4(S3-S4), witness 3(W3) and witness 6 (W6) A separate investigation was conducted Con'd on 9099-C Unsubstantiated by Department of Social Services Investigations Bureau Investigator Laura Garcia consisting of a request from home health and hospice records, records of hospitalizations, and interviews with staff 1-Staff 2(S1-S2) resident 3 (R3), Witness 1, Witness 2, Witness 4, and Witness 5 (W1, W2, W4 and W5). On 2/2/2024 LPA Shirley conducted a health and safety check and toured the facility with caregiver Nelly Salvador. The investigation revealed the following: Allegation: Staff neglect resulted in a resident sustaining multiple pressure injuries while in care It is alleged that resident had multiple pressure injuries. Investigation Branch's Department Investigator Laura Garcia conducted interviews with staff from this facility, facility residents, staff from Wound Masters wound care and reviewed medical records/reports. A review of records shows R1 resided at her own home and received hospice and home health care from Doring Care Management Services until her admittance to Comfort Home for the Elderly on 2/21/22. Investigator Laura Garcia interviewed staff from Doring Care Management (W1), who stated R1 sustained pressure injuries while under their care due to fragile skin and immobility. While at Comfort Home for Elderly, R1 received hospice services from Summer Breeze Hospice and Palliative Care and Wound Masters wound care. On 2/24/22 R1 was assessed by Wound Masters wound care services. Records from the wound care service indicate that resident had three pressure injuries upon admittance to the facility: Stage 2 to right heel, Stage 2 to left heel, Stage 4 to Sacro coccyx. Investigator Laura Garcia interviewed RN from Wound Masters, Witness 2 (W2) who stated that wounds were developed prior to R1’s move to Comfort Home for Elderly. A further review of progress notes dated from 2/24/22 to 6/14/22 from Wound Masters wound care show that by 3/17/22 pressure injury to R1’s right heel had healed. On 4/21/22 a stage 3 pressure injury was found on R1’s elbow. By 5/12/22 Stage 3 pressure injury to R1’s elbow had closed. Further review of notes by the wound care agency gives no indication of neglect by the facility. LPA Shirley spoke to staff from Wound Masters on 2/1/24, Witness 3 (W3) stated that Wound Masters staff had no concerns of neglect from facility staff. The Investigation Branch Departments Investigator Laura Garcia and LPA Shirley found there is no evidence to corroborate the allegation mentioned above. The information and evidence obtained did not sufficiently support the allegation. Con'd 9099-C Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff neglect resulted in a resident sustain multiple pressure injuries while in care” therefore the allegation is unsubstantiated. Allegation: Resident sustained an unexplained fracture while in care It is alleged that resident had a fractured hand. Investigation Branch's Department Investigator Laura Garcia conducted interviews and gathered records from staff from this facility, facility residents, home health/hospice agencies and hospitals. A review of medical reports received from UCLA Health-Medical Records show that on 1/7/22 R1 was admitted to UCLA Health for a closed fracture of the right hand. R1 was admitted to Comfort Home for Elderly on 2/21/22. A further review of records reviewed from Wound Masters wound care show no fractures sustained while R1 was under the care of Comfort Home for Elderly. Investigator Laura Garcia interviewed S1, S2, W1 and W2 regarding fractures, and all four stated the fracture did not occur while R1 resided at Comfort Home for Elderly. W1 of Doring Care Management further stated the fracture occurred under their care while R1 resided in her own home. The Investigation Branch Departments Investigator Laura Garcia found there is no evidence to corroborate the allegation mentioned above. The information and evidence obtained did not sufficiently support the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Resident sustained an unexplained fracture while in care,” therefore, the allegation is unsubstantiated. Allegation: Staff did not follow a resident’s dietary restrictions It is alleged that resident was receiving foods that were not part of her dietary plan. LPA Shirley reviewed facility records and found that the Physician’s Report dated 3/29/2022 shows that per doctor, the resident was currently on a pureed diet with thickened liquids. LPA Shirley interviewed S1, S2 and S3 and asked staff if they ever deviated from resident’s special diet. Of those interviewed, 2 out of 3 stated staff did not deviate from resident’s dietary restrictions. S3 stated that she did not work at this faciity while R1 was there, but did state that they do not deviate from special diets. Based on records review and interviews, there is not sufficient evidence to corroborate the allegation. Con'd 9099-c 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; therefore, the allegation of “Staff not following a resident’s dietary restrictions,” is found to be unsubstantiated. Allegation: Facility admitted resident that needed a higher level of care It is alleged that resident was not a good fit for facility and needed a higher level of care due to needing full assistance with multiple diagnoses. LPA Shirley reviewed the facility file and found that the facility has a current and valid fire clearance for bedridden residents. A review of medical reports received from UCLA Health-Medical Records show that on 1/7/22 R1 was admitted to UCLA Health for a closed fracture of right hand, while R1 lived on her own and not under the care of the facility. LPA Felisa Shirley reviewed home health and wound care records records and found that R1 resided at her own home and received hospice and home health care from Doring Care Management Services until her admittance to Comfort Home for the Elderly on 2/21/22. Investigator Laura Garcia interviewed staff from Doring Care Management (W1), who stated R1 sustained pressure injuries while under their care due to fragile skin and immobility. When R1 entered facility on 2/21/2022, she did so with services from Summer Breeze Hospice and Palliative Care and Wound Masters wound care. A further review of files shows that the facility had a plan of care in place for resident’s care. A further review of hospice records shows that an oxygen concentrator was part of the inventory for R1, not a ventilator. With the care plan in place, the facility staff in conjunction with the various care agencies providing direct services and care to the resident, the facility did not admit or retain the resident beyond their ability to provide care. Based on records review and interviews, there is not sufficient evidence to corroborate the allegation. 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; therefore, the allegation of “Facility admitted resident that needed a higher level of care,” is found to be unsubstantiated. An exit interview was conducted, and a copy of the LIC 9099 report was provided to Socorro Trinidad.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 11-AS-20231002112925