COMFORT ZONE CAL

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) , the licensee did not comply with the section cited above in water in the bathrooms and kitchen was delivered at 146.6 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/09/2026 Plan of Correction LIcensee will get water temperature adjusted to regulations during today's visit.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in one out of one staff working currently does not have a current valid CPR/First aid valid certificate which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2026 Plan of Correction Licensee will have staff be certified by 01/16/2026. and will email LPA proof of certificate.

Official classification

Type A

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on (record review)], the licensee did not comply with the section cited above as of one staff out of one which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2026 Plan of Correction LIcensee will ensure that staff receives a heakth screening by POC date, and will email proof of the Health screening via email to LPA.

Official classification

Type A

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on (record review)], the licensee did not comply with the section cited above in [count] out of one of one staff did not have on record training, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/30/2026 Plan of Correction Licensee will provide all required training to staff by POC date and will submit a copy of the training topics with dates, hours completed, and time the staff received the training along with the instructors credentials, name, etc.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on medication audit and (record review)], the licensee did not comply with the section cited above in [3] out of [3) medications were incorrectly administered, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/23/2026 Plan of Correction Licensee will ensure that staff receive training in medication administration by a certified instructor, The Licensee will email the LPA verification and proof of the complated training, along with the cerdential of the instructor by the POC date.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) the toilet in barthroom #2 the licensee did not comply with the section cited above in two out of two plumbing fixtures need to be unclogged, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/17/2026 Plan of Correction Licensee will provide video or paperwork for plumbing services that corrected the deficiencies by the POC date.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation), the licensee did not comply with the section cited above in one out of one wall needs repair, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2026 Plan of Correction Licensee will provide paperwork for repair work which decribes the wall repair by the POC date.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews conducted, the Licensee did not comply with the section cited above as two (2) smoke alarms were observed to be beeping indicating change of battery which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/28/2024 Plan of Correction Licensee agrees to replace the batteries for the two (2) smoke alarms by due date.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above, as two (2) out of four (4) residents are bedridden and the fire clearance only allows one (1) bedridden resident which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 02/28/2024 Plan of Correction The Administrator stated that R1 is going to get a new medical assessment to confirm R1’s status.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the licensee did not comply with the section cited above, as the outside patio ramp has a hole which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction The Licensee stated that she will do the following: 1. Ensure that the patio is in good repair by due date.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above as the facility had insufficient supply of perishable and non-perishable food which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/01/2024 Plan of Correction The Licensee stated that she will: 1. Go grocery shopping and ensure that the facility has sufficient supply of perishable and non-perishable food and send proof to the LPA.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health… shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance as specified... This requirement is not met as evidenced by: Based on record review and interview the Licensee did not comply with the section cited by not transferring the criminal record clearance for S1 to this facility prior to employment which poses an immediate health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee agreed to submit a transfer of a criminal record clearance for all staff not associated to the facility by 11/02/2023. Civil Penalties assessed in the amount of $100.

Deadline recorded: Nov 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506(a) 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 evidenced by: Based on record review, the Licensee did not comply with the section cited above as there were no files or incomplete files present at the facility for R1, R2, R3 and R4 which poses a potential health and safety risk to residents in care.

Official plan of correction

The Licensee stated that she will ensure that all residents will have completed files by due date.

Deadline recorded: Nov 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on interviews and documents reviewed, the licensee did not comply with the section cited above as the facility did not submit the unusual incent/injury report for R1 within 7 days of occurrence to CCL, which poses a potential health & safety risk to residents in care.

Official plan of correction

POC: The Licensee will submit a plan detailing how the facility will maintain in compliance of Regulation 87211 and submit to CCL by 04/24/2023.

Deadline recorded: Apr 24, 2023. A deadline is not proof that correction was completed.