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Inspection visit

Follow-up on corrections

COMFORT HOME 2License 3664260812 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

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.

Citations

2 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87608(a)(3)Type B

    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.

  • 87705(I)(2)Type A

    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.

FAQ · About this visit

Common questions about this visit

What happened during the November 17, 2023 inspection of COMFORT HOME 2?

This was a other inspection of COMFORT HOME 2 on November 17, 2023. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to COMFORT HOME 2 on November 17, 2023?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indi..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.