Comfort Home RCFE

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a required annual inspection. LPA identified herself to staff who were advised of the purpose of the visit and S1 phoned licensee Sushma Lal. Licensee Lal arrived shortly and was also informed of the reason for the visit. The facility is currently licensed as a Residential Care Facility for Elderly, with a capacity of four non ambulatory and two ambulatory residents only. All residents and some visitors are present during today's visit. LPA Bueno and staff Hoyos toured the facility inside while LPA and Licensee toured the exterior of the facility. Licensee left the facility prior to the conclusion of the inspection Buildings and Grounds: The home has 5 bedrooms, two bathrooms, a sitting room/office area, a laundry room, a TV/sitting area, and a kitchen and dining area. The facility has no bodies of water. There is a backyard patio with ample seating. LPA and Licensee observed that the side gate is locked but free of obstruction. The facility has a working telephone available for use. There is charged fire extinguisher. S1 tested resident bedroom smoke alarms and LPA tested hallway carbon monoxide detector. LPA and S1 found all units to be in working order. Storage and Supplies: Activities were observed to be available near the office area and in the TV are. A locked centralized closet is utilized for medications while client and staff files are secured in the office area. The first aid kit was observed to be available and complete. Linens, and equipment are all in good repair and sufficient for approved census. Food Service and Laundry: LPA and S1 observed two days of perishable food items and 7 days of non- perishables. Utensils and dishware are sufficient for the capacity. The refrigerator and stove are in working order. Sharps are kept locked while toxins and cleaning agents are secured in cabinets, inaccessible to residents. Bedrooms and Bathrooms: Resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. LPA and Licensee observed the water temperature to be 109 degrees Fahrenheit. Facility Files and Medication: LPA inspected all resident files and found that it had the required documentation including an admissions agreement and current physician's repor. LPA reviewed three of three staff files with one current first aid certification and two expired. LPA found training records but were not current. LPA reviewed all resident medications and found R1's medication (M1) being administered but is not on the centralized log. Licensee updated personnel report, and will send a current LIC 610E, emergency disaster plan to LPA. Deficiencies which pose immediate and potential health, safety or personal rights risk to residents in care. Refer to LIC809Ds for deficiencies issued during today's visit. An exit interview was conducted by telephone with Licensee and a copy was signed by and provided to S2 at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Sep 11, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 06/20/2022 at 08:25 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with staff Anayeli Hoyos and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrators Harish Lal and Sirish Lal were contacted and informed of the visit. Staff Hoyos reported that they have five (5) residents at the facility. Administrator Sirish Lal arrived during the visit. Below is a summary of what was observed: Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Lal. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing, and signs have been posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect residents from infection during pandemic. However, LPA Brown noticed no central entry point has been designated for universal entry screening, no routine symptom screening like temperature and symptom check has been initiated at entry for all staff, residents and visitors. In addition, LPA Brown observed facility are not documenting daily temperature and Covid-19 symptom checks and any change in condition for staff in order to track spread. Moreover, during the visit, LPA Brown observed two (2) staff not wearing mask while in the facility. LPA Brown will be issuing a Technical Advisory Note for this items. LPA Brown toured the facility's and all rooms and bathrooms have hand soap and paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE. LPA Brown went over the various recommended training for facility staff with Administrator Lal in relation to COVID-19 and Administrator Lal informed LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. **** Continuation in LIC809C **** LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Lal informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, LPA Brown observed all residents and all staff have been vaccinated and boosted and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their residents, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their residents regularly for any changes in condition and to subsequently notify the residents physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. During the tour of the facility on 06/20/2022 at 08:45 AM, LPA Brown observed the smoke detectors in bedroom 1, bedroom 2 and bedroom 3 to be non-operable. Licensee was able to obtain a battery for the smoke detector but unable to replace the three (3) non-operable smoke detectors. Administrator Lal reported that she will contact the facility handyman today to replace the three (3) non-operable smoke detectors. LPA Brown informed Administrator Lal that deficiency will be issued as this poses immediate risk to residents in care. During the visit, LPA Brown requested staff vaccination records and on 06/20/2022 at 09:00 AM, LPA Brown observed all staff have dose 1, dose 2 and booster. Administrator LaL showed proof of vaccinations/booster record to LPA Brown during the visit. In addition, per review of staff records, LPA Brown observed Staff 3 and Staff 6 not associated at the facility. LPA Brown informed Administrator Lal that citation will be issued as this poses potential risk to clients in care. An exit interview was conducted with Administrator Sirish Lal and a copy of this report (LIC809), LIC 809D, LIC9102 TA Advisory Notes and Appeal Rights were discussed and provided.the state’s words, verbatim · CDSS document, Jun 20, 2022

The state marks this report as 9 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 3:45 PM, LPA were met by Caregiver Araceli Tchouldjian and explained the purpose of the visit. Present in the facility during time of visit were one (1) staff as well as six (6) residents. Licensee Sushama Lal arrived and joined the inspection. There are currently no cases of COVID-19 within the facility. During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, Administrator will order additional supplies, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor resident(s) regularly for any changes in condition and to subsequently notify the resident(s) physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 5, 2021