<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530219
Report Date: 09/23/2026
Date Signed: 09/23/2026 10:10:33 PM

Document Has Been Signed on 09/23/2026 10:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SOUTHERN COMFORT CARE HOME 2FACILITY NUMBER:
335530219
ADMINISTRATOR/
DIRECTOR:		RIMORIN, MAE SHANDAFACILITY TYPE:
740
ADDRESS:32826 BIRCHALL COURTTELEPHONE:
(310) 975-5634
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 2DATE:
09/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:Caregiver Jae Rimorin and Caregiver Marshall BassTIME VISIT/
INSPECTION COMPLETED:
10:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Andrew Martinez arrived unannounced to conduct the required annual comprehensive inspection of the facility. LPA was greeted by Caregiver Eve Cisneros Cortez and Caregiver Marshall Bass Morales, explained the purpose of the visit and was granted access to the facility. LPA was informed that the current census is two (2) residents, with the two (2) staff members present in the facility. Licensee Joanne Castin was contacted by facility staff to inform them of LPA's presence. Licensee stated Administrator Shanda Rimorin was unavailable due to an emergency. Licensee Joanne Castin assisted facility staff and LPA via telephone calls.

The facility is a single-story home with five (5) resident bedrooms, three (3) bathrooms, one (1) staff bedroom, kitchen, dining area, living room, laundry room, backyard and attached two and a half (2 1/2) car garage. LPA was accompanied by Caregiver Eve to conduct a general overall inspection of the facility which included but was not limited to the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). LPA observed there are no obstructions to indoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit (F). Facility water temperature was measured at 109 degrees F. LPA inspected all resident bedrooms observing four (4) of (5) to be equipped with required furniture such as mattresses, nightstands, storage space, chairs, and sufficient lighting; (1) resident, Resident #1's (R1), bedroom was observed to be without a bed. Licensee disclosed to LPA that bedding furniture was initally provided to R1 at time of admission, however, R1 declines used of bed and elects to sleep in her own recliner(s). Licensee stated R1's family and physician are aware of R1's refusal of use of bed and election to use her recliner(s) only, but no documentation has been obtained/retained approving this exception. One (1) Type B deficiency will be issued. LPA inspected resident bathrooms which were observed to be clean with all plumbing fixtures found operational and in working order. LPA observed multiple waste receptacles located within resident bedrooms and bathrooms to be without a tight-fitting cover. One (1) Type B deficiency will be issued.
*** Continued on LIC 809-C ***
Karen Clemons
Andrew Martinez
DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SOUTHERN COMFORT CARE HOME 2
FACILITY NUMBER: 335530219
VISIT DATE: 09/23/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The facility is equipped with combination smoke alarm and carbon monoxide detectors that were tested and observed to be working properly. Two (2) fully charged fire extinguishers were observed in the facility. LPA observed the facility maintains a fully stocked first aid kit, however, the facility's First Aid Manual could not be located by staff. Licensee purchased a replacement during LPA's visit and provided proof of purchase to LPA. One (1) Technical Violation will be issued. Posters such as the Resident Personal Rights, Long Term Care Ombudsman, CCL complaint poster, emergency phone numbers, and emergency disaster plans were all posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident and staff records/files. There are no pools or open bodies of water, no fireplace observed, and no guns, ammunition, or other dangerous weapon are stated to be stored on property.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly.

Yards/Outside: Facility has one shaded patio, and a side gate with self-latching handle on the northeast side of the house that leads into the backyard. LPA observed the facility's four (4) large residential solid waste bins were to be obstructing the outdoor passageway leading out of the side gate from the back to the front of the property. Facility staff relocated all four (4) solid waste bins to another location to clear the outdoor passageway prior to LPA completing visit. One (1) Type B violation will be issued and cleared as a same-day correction.

Medications: Medications were observed secured, centrally stored, and are kept inaccessible to residents in care. Medications were audited at random by LPA. Medication audit revealed that one (1) resident's (R1) medication was observed to be stored without a medication label, and one (1) resident's (R1) medication was being transferred from its originally stored medication container into another. Two (2) Type A deficiencies will be issued. Licensee stated the Administrator pre-sorts residents' medications in the morning by transferring residents' medication that was stored in its originally received container into separate daily pill organizer containers. Licensee also stated facility is awaiting to establish care for R1 with a primary care physician to complete orders for R1's current medications.

Care & Supervision: The facility has sufficient care staff for coverage 24 hours a day, 7 days a week.
*** Continued on LIC 809-C ***
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC809 (FAS) - (06/04)
Page: 3 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SOUTHERN COMFORT CARE HOME 2
FACILITY NUMBER: 335530219
VISIT DATE: 09/23/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Record Review: LPA reviewed resident record files for admission agreements, updated physician reports, and needs and services plans. Resident record file reviews revealed that two (2) of two (2) resident's record file contained incomplete and/or unsigned admissions agreements from either the resident, a resident representative and/or the licensee or licensee's designee. Resident record file reviews also revealed that two (2) of two (2) resident's record file did not contain pre-placement appraisals. Two (2) Type B deficiencies will be issued.

LPA reviewed employee personnel files for criminal background clearances, medical assessments/health screening report including Tuberculosis (TB) test results, CPR/First Aid certifications, and required training. Employee personnel file reviews revealed that all personnel records were not available for Licensing for inspection, and all personnel records were not maintained at the facility for at least two (2) staff; staff #1 (S1) and staff #2 (S2). Two (2) Type B deficiencies will be issued. Employee personnel file reviews also revealed that (1) staff member (S2) could not provide a health care screening with TB test results to be verified by LPA, and one (1) staff member's (staff #3 (S3)) health screening report was incomplete. One (1) Type A deficiency will be issued. Furthermore, employee personnel file reviews revealed one (1) staff member's criminal record clearance was not transferred appropriately to the facility. LPA verified through the online Guarding Background Check System that staff #2 (S2) was not associated to facility. One (1) Type A deficiency will be issued.

LPA reviewed facility records for valid liability insurance, reviewed and/or updated Infection Control Plan, reviewed and/or updated Emergency and Disaster Plans, quarterly emergency drills, and Designation(s) of Facility Responsibility. Review of facility records revealed the facility did not designate an authorized person who is continuously present at the facility during operational hours to represent the facility and to accept licensing reports. LPA observed the posted Designation of Facility Responsibility LIC 308 form, signed and dated on 10/01/2025 by Licensee, designates an individual who also is not reflected on the facility's Personnel Report LIC 500. Licensee Joanne Castin and Administrator Shanda Rimorin were not on property for the duration of LPAs visit. One (1) Type A deficiency will be issued.

Based on LPA's observation, interviews, and record reviews, five (5) Type A deficiencies, seven (7) Type B deficiencies, and one (1) Technical Violations are being cited per Title 22 California Code of Regulations. An exit interview was conducted where this Facility Evaluation Report (LIC 809/LIC 809-Cs/LIC 809-D) were discussed, and Plans of Corrections were developed between LPA and Licensee. Copies of all above-stated reports, along with Appeal Rights, were left for Licensee Joanne Castin and Administrator Shanda Rimorin at the conclusion of the visit, in the care of Caregiver Marshall Bass Morales whose signature on all forms confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Andrew Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 09/23/2026 10:10 PM - It Cannot Be Edited


Created By: Andrew Martinez On 09/23/2026 at 07:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SOUTHERN COMFORT CARE HOME 2
FACILITY NUMBER: 335530219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not being able to provide a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment for [1] out of [1] employee, Staff #2 (S2), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2026
Plan of Correction
1
2
3
4
Licensee agrees to review cited regulation in full, complete a statement of understanding of cited regulation, and provide Licensing with a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to employment for Staff #2 (S2). Licensee is to submitted both the statement of understanding and health screening report to Licensing via email by the Close of Business (COB) on Plan of Correction (POC) due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 09/23/2026 10:10 PM - It Cannot Be Edited


Created By: Andrew Martinez On 09/23/2026 at 07:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SOUTHERN COMFORT CARE HOME 2
FACILITY NUMBER: 335530219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in by not having [1] out of [1] employee's, Staff #2 (S2), criminal record clearance transferred properly to the facility's Guardian profile prior to working or volunteering in the licensed facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2026
Plan of Correction
1
2
3
4
Licensee agrees to review cited regulation in full, complete a statement of understanding of cited regulation, and provide Licensing with the statement of understanding and proof of completed transfer of Staff #2's (S2) criminal record clearance to the facility's Guardian profile to show proper eligibility clearance, submitted via email by the Close of Business (COB) on Plan of Correction (POC) due date.
Type A
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not designating a substitute, at least 21 years of age with qualifications adequate to be responsible and accountable for the management and administration of the facility, who shall be on the premises 24 hours per day which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2026
Plan of Correction
1
2
3
4
Licensee agrees to review cited regulation in full, complete a statement of understanding of cited regulation, and complete a new Designation of Facility Responsibility LIC 308 desingating a substitute to be responsible and accountable for the management and administration of the facility who shall be on the premises 24 hours. Licensee is to submit statement of understanding and LIC 308 to Licensing via email by COB on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 09/23/2026 10:10 PM - It Cannot Be Edited


Created By: Andrew Martinez On 09/23/2026 at 07:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SOUTHERN COMFORT CARE HOME 2
FACILITY NUMBER: 335530219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in not ensuring all centrally stored medications were labeled and maintained with in compliance with state and federal laws for [1] out of [1] residents, Resident #1 (R1), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2026
Plan of Correction
1
2
3
4
Licensee agrees to review the cited regulation in full, complete a statement of understanding of cited regulation, and provide in-service training for all employees on regulation that meets the requirements found in Section 87411(c)(6). Licensee is to submit the statement of understanding and proof of training as required in Section 87411(c)(6) to LPA via email by Close of Business (COB) on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above by stating the Administrator pre-sorts residents medications in the morning by transferring residents' medication that was stored in its originally received container into separate daily pill organizer containers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2026
Plan of Correction
1
2
3
4
Licensee agreed to immediately discontinue the pre-sorting of residents' medications. Licensee agrees to review the cited regulation in full, complete a statement of understanding of cited regulation, and provide in-service training for all employees on regulation that meets the requirements found in Section 87411(c)(6). Licensee is to submit the statement of understanding and proof of training(s) to LPA via email by COB on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 09/23/2026 10:10 PM - It Cannot Be Edited


Created By: Andrew Martinez On 09/23/2026 at 07:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SOUTHERN COMFORT CARE HOME 2
FACILITY NUMBER: 335530219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)(D)
Infection Control Requirements
(2) Environmental cleaning and disinfection activities shall be performed following the manufacturers'instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by ensuring that all the waste receptacles within the facility are equipped tight-fitting covers which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
1
2
3
4
Licensee agrees to review the cited regulation in full, complete a statement of understanding of cited regulation, provide in-service training for all employees on regulation meeting the requirements found in Section 87411(c)(6), and procure waste receptacles with tight-fitting covers and replace those within the facility that are without. Licensee is to submit the statement and proof of training to LPA via email by Close of Business (COB) on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87307(a)(3)(A)
Personal Accommodations and Services
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in providing a bed in [1] out of [1] resident's (R1) room without approved exception from Licensing and documentation from R1's responsible party and attending physician stating R1 can be without a bed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
1
2
3
4
Licensee agrees to review the cited regulation in full, complete a statement of understanding of cited regulation, and submit a written request for an exception from Licensing to be able to not supply a bed for R1 in R1's bedroom along with documentation from R1's responsible party and attending physician that states R1 can be without a bed. Licensee is to submit the statement and request for exception along with requested documentation to Licensing by COB of POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 09/23/2026 10:10 PM - It Cannot Be Edited


Created By: Andrew Martinez On 09/23/2026 at 07:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SOUTHERN COMFORT CARE HOME 2
FACILITY NUMBER: 335530219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by ensuring the facility's [4] out of [4] large residential solid waste bins were not obstructing the outdoor passageway on the northeast side of the facility, leading out of the side gate from the back to the front of the property, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
1
2
3
4
Licensee had facility staff relocate all four (4) solid waste bins to another location to clear the outdoor passageway on the northeast side of the facility, leading out of the side gate from the back to the front of the property, prior to LPA completing the facility evaluation visit. LPA will clear Plan of Correction (POC) as a same-day correction.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having [2] out of [2] employee personnel records for Staff #1 (S1) and Staff #2 (S2) available for Licensing to inspect during LPA's facility evaluation visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
1
2
3
4
Licensee agrees to review the cited regulation in full, complete a statement of understanding of cited regulation, and provide photographic proof that S1 and S2's employees full personnel records are Licensee possession and stored at the facility. Licensee is to provide the statement and photographs via email to Licensing by Close of Business (COB) of POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 09/23/2026 10:10 PM - It Cannot Be Edited


Created By: Andrew Martinez On 09/23/2026 at 07:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SOUTHERN COMFORT CARE HOME 2
FACILITY NUMBER: 335530219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above not ensuring all personnel records are maintained at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
1
2
3
4
Licensee agrees to review the cited regulation in full, complete a statement of understanding of cited regulation, and provide in-service training for the appropraiate employees on regulation that meets the requirements found in Section 87411(c)(6). Licensee is to submit the statement of understanding and proof of training(s) as required in Section 87411(c)(6) to Licensing via email by Close of Business (COB) on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in not ensuring a pre-admission appraisal was maintained in [2] out of [2] resident's record files for Resident #1 (R1) and Resident #2 (R2) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2026
Plan of Correction
1
2
3
4
Licensee agrees to review the cited regulation in full, complete a statement of understanding of cited regulation, provide in-service training for the appropriate employees on regulation that meets the requirements found in Section 87411(c)(6), and locate R1 and R2's pre-admission appraisals. Licensee is to submit the statement, proof of training(s) as required in Section 87411(c)(6), and R1 and R2's pre-admission appraisals to Licensing via email by COB on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 10 of 12
Document Has Been Signed on 09/23/2026 10:10 PM - It Cannot Be Edited


Created By: Andrew Martinez On 09/23/2026 at 07:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SOUTHERN COMFORT CARE HOME 2
FACILITY NUMBER: 335530219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above not ensuring the admissions agreements were signed and dated, by the resident or the resident's representative, if any, and/or by the licensee or the licensee's designated representative no later than seven days following admission for [2] out of [2] residents, R1 and R2, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2026
Plan of Correction
1
2
3
4
Licensee agrees to review the cited regulation in full, complete a statement of understanding of cited regulation, provide in-service training for the appropraiate employees on regulation that meets requirements found in Section 87411(c)(6), and obtain all necessary signatures on R1 and R2's admissions agreements. Licensee is to submit the statement, proof of training(s), and proof of signatures to Licensing via email by Close of Business on Plan of Correction due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Andrew Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 11 of 12