Comfort Hospice, Inc.
A hospice in San Marino, California 91108
1635 Chelsea Road, San Marino, California 91108. (818) 238-0087.
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The short answer
Record last released by CMS on Oct 23, 2026. We couldn’t read Centers for Medicare & Medicaid Services’ list since Oct 27, 2026: qcor.cms.gov now refuses our reader. This record is as of then.
- 5 deficiencies cited in the last three years
- Not rated family caregiver rating
- 9of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
5 deficiencies cited in the last three years
The middle of the 53 hospices serving ZIP code 91108 had 5.
The last inspection on record was on Nov 6, 2025: a reaccreditation inspection by The Joint Commission.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
5 deficiencies in 1 month of the last 36. Last cited Nov 2025. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Nov 6, 2025: reaccreditation inspection by The Joint Commission5 deficiencies
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Content of comprehensive assessment (42 CFR 418.54(c)(6)(i))
The inspectors’ words, 103 words
“Observed in Individual Tracer. In 1 of 3 home visits conducted, The surveyor noted (RRHV#2) that the nurse did not follow the policy for medication reconciliation. The nurse did not have a copy of the plan of care or the current medication profile available, when completing the medication reconciliation during the home visit. The nurse looked at all the medications; however, did not compare them to any document to insure the medication list was complete and accurate. The organizational policy required that a medication reconciliation be complete each SN visit, comparing the medications to the medication list. This was confirmed with the administrator.”
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Content of comprehensive assessment (42 CFR 418.54(c)(8))
“Observed in Individual Tracer. In 2 of 10 patient records reviewed, The surveyor noted (RRHV#1) that there was no evidence in the patient record that the nurse or IDT assessed for the need for volunteer services to offer support or respite to the patient, family, or other caregivers. This was also noted in (RRHV#2). This was confirmed with the director.”
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Content of plan of care (42 CFR 418.56(c)(3))
“Observed in Record Review. In 1 of 10 patient records reviewed, The surveyor noted (RRNHV#8) that the nursing assessment of August indicated that the patient was experiencing new onset shoulder pain rated at 10/10 on a scale of 1 to 10. There was no evidence in the plan of care or IDG meeting notes that the plan of care was updated with goals and interventions to manage the pain, as required by policy 9.12.3. This was confirmed with the director.”
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Program activities (42 CFR 418.58(c)(3))
“Observed in Data Session. In 3 of 3 years, The surveyor noted that the organization had identified a process improvement goal for improvement in hand hygiene for 2024 and 2025; however there was no evidence in the QAPI data that hand hygiene compliance had improved. There was no evidence in any of the data collected that any outcomes had been evaluated for effectiveness or improved over time, for the last three years. This was confirmed with the administrator.”
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Personnel qualification (42 CFR 418.114(a))
“Observed in Competency Session. In 2 of 12 HR files reviewed, The surveyor noted that the credentials were not verified that the employee had the credentials required by the job description for the chaplain or the social worker when hired (HR#10BCCH) and (HR#11MSSW). The files only contained copies of diplomas and a credential card with no evidence of verification that they were authentic. This was confirmed with the HR manager and corrected on site.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Nov 6, 2025 | Reaccreditation inspection by The Joint Commission | 5 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Sep 30, 2016.
- Ownership: for-profit.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 15.5 nurse care minutes per routine home care day, 7.2% of skilled nursing minutes at weekends and a visit near death for 91.9% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 12% at home, 88% in assisted living.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 15.5 min |
| Skilled nursing minutes at weekends | 7.2% |
| Visits near death | 91.9% of patients who died |
Who owns it?
- CMS’s ownership file has no owners listed for this hospice.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- CMS’s Hospice Care Index: 9 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 84.76% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 4.9% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | Not rated |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 9 of 10 |
How does it compare nearby?
- Of the 53 hospices CMS’s data show serving patients in ZIP code 91108, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 5; this one had 5.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Comfort Hospice, Inc. This hospice | 5 |
| Peaceful Journey Hospice Care, Inc. | Not given |
| Kaiser Foundation Hospital Los Angeles - Hospice | 3 |
| Vitas Healthcare Corp | 18 |
| Mission Hospice | 15 |
| Assurance Hospice, Inc. | Not given |
| Grace Hospice, Inc. | 10 |
| Active Hospice Care, Inc. | 5 |
| Silverado Hospice-Los Angeles | 15 |
| Bristol Hospice- Northern Los Angeles | 7 |
| Faith & Hope Hospice Care, Inc. | 6 |
| Five Star Home Hospice | 3 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.