Southern Comfort Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual inspection. LPA was greeted and granted entry by Caregiver Dave Benito after stating the reason for the visit. Administrator Rachel Tutop shortly arrived to assist with the inspection. Administrator Tutop has a valid certificate expiring April 25, 2028. The following was observed during the inspection: This is a single story residential home. Facility is approved for six non-ambulatory of which 1 may be bedridden. The fire clearance approved bedridden resident to occupy Bedroom A, and a waiver was granted for hospice care of 6. LPA observed two staff on duty and four residents in care of which two are on hospice. Three residents were observed in the living room relaxing and watching television while one was was resting in their bedroom. Resident #1 (R1) is the only bedridden resident in the facility according to the Physician's Report (LIC602), and occupies Bedroom D. Resident #2 (R2) is non-ambulatory and occupies Bedroom A. Admin Tutop indicated that although R1 is marked as bedridden, R1 is considered non-ambulatory evidenced by R1 sitting in the recliner of the living room. Admin Tutop indicated that the LIC602 will be updated for R1. LPA verified fingerprint clearance and association status of staff. LPA observed two private and two shared resident bedrooms. All residents' bedrooms have the required furnishings and ample lighting. There are two and a half resident bathrooms of which one is a private bathroom dedicated to R2. The bathrooms are found to be in compliance equipped with grab bars and slip resistant mats. However, the shared full bathroom requires a deep cleaning of the toilet and floor evidenced by the presence of urine odor and mildew surrounding the perimeter of the shower floor. The hot water temperature measured at 115.5 in the half bath, 110.3 in the private bathroom, and 110.6 degrees Fahrenheit in the shared bathroom. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed ample two day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway is free of obstruction. The exit gate is operational, and there were sufficient seating and shading. The fire extinguishers were serviced by the Orange County Fire Authority on July 13, 2026. The auditory devices and dual functioning smoke/carbon monoxide detectors were tested and found operational. The air conditioning (AC) unit was not operating to provide cool air. Admin indicated working receiving estimates to reinstall a new AC unit. Multiple fans were placed in each rooms to provide cool air during the heat wave. Admin to communicate the progress and status of the repair. LPA observed at least three days of emergency food and water. Disaster drills are conducted quarterly with the last date on August 4, 2026. The Emergency Disaster Plan (LIC610E) was reviewed and updated annually as required. LPA observed the required 'See Something, Say Something' (PUB475) poster posted in the correct size in the entry way. LPA audited four residents' and three personnel files in which no discrepancies were found. Medications were audited for two of four residents. No discrepancies found with administration. However, staff was reminded to complete documentation within a timely manner. Based on the observations made during today's visit, no deficiency is being cited. Advisory Notes are being issued. An exit interview was conducted with Administrator Rachel Tutop, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Aug 26, 2026

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1 at 8:10am. During today’s visit, LPA met with Joanne Casten, Licensee and Luisito "Ramon" Casten, Administrator. The facility is a four bedroom, three bathroom single story home with an approved fire clearance of six non-ambulatory residents of which one may be bedridden. The facility currently has a census of five residents in care. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 116.2 to 119.4 degrees Fahrenheit and all smoke and carbon monoxide detectors were operational. The fire extinguisher is charged and was serviced on January 10, 2025. The facility’s last fire drill was conducted on July 1, 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. Sharps and knives and cleaning chemicals are secured beneath the sink. A menu was posted and the refrigerator had a variety of food and the canned goods in the pantry was full. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. A first aid kit is mounted on the wall with the required elements and a First Aid Manual is on the premises. A scan thermometer is located at the entrance. (Continued on LIC 809-C) (Continued from LIC 809) LPA toured the exterior of the property and observed no hazards or obstructions in pathways. There was a shaded seating area for residents. The garage stored emergency supplies and water and Meals Ready to Eat (MRE) supplies. There is an indoor camera that is visual only. LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on February 4, 2026. LPA confirmed contact information and that licensees are a partnership. The preferred language is English and an invoice for licensing fees was given to the Administrator. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Joanne Casten, Licensee and Luisito "Ramon" Casten, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Aug 5, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Jessica Cho conducted an announced subsequent Pre-Licensing continuation visit. LPA Cho was allowed entry and met with Applicant Joanne Casten. The purpose of today's visit was to follow-up on the issues that were present during the initial Pre-Licensing visit on July 24, 2024. The following issues below were observed and required correction: To repair by patching the holes in the ceiling by the half bath and ensuring exit gate self-latches. To deep clean the floor, kitchen, and kitchen appliances, sweep the backyard, wash the outdoor cushions and furniture to remove dust and cobwebs. To remove or cover the exposed cable in the living room and remove the bricks/shelf in the exit passageway. To obtain the current edition of the first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency and the Long Term Care Ombudsman Poster and post it in the entry way. To post a copy of the admission agreement. To label the inspection dates on the fire extinguishers. Component III is waived due to the applicant previously having a licensed facility and having completed Component III. LPA provided a refresher consultation answering questions for the Applicant during the visit. On today's visit the aforementioned items have been addressed and corrected. The aforementioned items reviewed during this visit are in compliance. The Pre-Licensing is now complete. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. An exit interview was conducted, and a copy of this report was provided at the time of this visit.the state’s words, verbatim · CDSS document, Jul 29, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility announced for the purpose of conducting a Pre-Licensing visit for a change of ownership and facility type. LPA conducted the visit with Applicant Joanne Casten. An initial application to operate a Residential Facility for the Elderly was received by the Department of Social Services on February 5, 2024, for a capacity of 6 residents. LPA toured the interior and exterior portion of the facility and observed the following accompanied by the Applicant Casten: Structure: Facility is a single story residential property comprised of four resident bathrooms and two full baths and one half bath. There is an attached two car garage, laundry room by the kitchen, and a backyard. Signal System: The facility does not have a signal system but is intending to purchase a signal system where the staff will be alerted in a central location. Bedrooms: The resident bedrooms had all required components, are spacious, and easily accommodates the residents’ furnishings. Bathrooms: Bathrooms were clean and operational. Grab bars were secure. Linens and Hygiene Supplies: Clean linens were observed to be fully stocked. Appliances: Stove burners, microwaves, washers, and dryers were inspected. Emergency Phone Numbers/Exit Plan: Posted in the kitchen area and readily available for review. Postings: The Complaint Poster (PUB475) was posted in the entry area of the facility. The Long Term Care Ombudsman Poster was not available. The Rights of the Resident Councils, Resident's Rights, Theft & Loss Policy, and the Activity Schedule were posted in the entry way or kitchen. Facility did not post a copy of the admission agreement. Food Service and Menu: Supply of seven day non-perishable and two day perishables were observed. The sample menu was available for review. The emergency food/water supply was stored in the kitchen pantry expiring in 2028. Smoke and Carbon Monoxide Detectors: Smoke detector and carbon monoxide alert systems were tested and found to be operational. Fire Extinguishers: Two fire extinguishers were mounted, fully charged, and serviced on March 13, 2024 which was unlabeled. One small extinguisher is in the company vehicle. Fire Clearance: Approved on March 13, 2024 for 5 non-ambulatory and 1 bedridden resident. Toxins and Sharps: Cleaning supplies, toxins, and sharps were secured. Water Temperature: Three resident bathrooms tested measuring at 113.9, 109.9, 103.5 degrees Fahrenheit. Medications, First Aid Kit & Manual: The First Aid Kit was checked and found to be in order. The First Aid kit is located in the kitchen area and in the company vehicle. The facility does not have the current edition of the First Aid manual. Resident and Staff Files: Resident and staff records will be maintained on site. Reading Material, Games, Equipment, & Materials: The facility had reading material and games present in the facility. Component III: Component III is waived due to the applicant previously having a licensed facility and having completed Component III. The following items need correction prior to licensure: Please repair by patching the holes in the ceiling by the half bath and the exit gate self-latches. Please deep clean the floor, kitchen, and kitchen appliances, sweep the backyard, wash the outdoor cushions and furniture to remove dust and cobwebs. Please remove or cover the exposed cable in the living room and remove the bricks/shelf in the exit passageway. Please obtain the current edition of the first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency and the Long Term Care Ombudsman Poster and post it in the entry way. Please post a copy of the admission agreement. Please label the inspection dates on the fire extinguishers. Facility does not appear ready for licensure. Any items noted above during today’s visit are to be corrected by Monday July 29, 2024 before 7:00am. An exit interview was conducted with Applicant Joanne Casten, and a copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 24, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOFT Capacity: 6 Interview Method: Telephone interview On 7/9/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. 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, Jul 9, 2024