California Comfort Care, LLC
A hospice in Walnut, California 91789
18800 Amar Rd Suite B16, Walnut, California 91789. (626) 332-0311.
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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.
- 20 deficiencies cited in the last three years
- Not rated family caregiver rating
- Not available CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean3
- 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.
- Condition-level deficiency
- 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.
What did inspectors find?
20 deficiencies cited in the last three years
The middle of the 134 hospices serving ZIP code 91789 had 8.
The last inspection on record was on Oct 28, 2024: an initial follow-up inspection by the Accreditation Commission for Health Care.
3 deficiencies at condition level, the more serious of CMS’s two levels
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
20 deficiencies in 1 month of the last 36. Last cited Sep 2024. Most serious: Condition-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.
Sep 11, 2024: initial inspection by the Accreditation Commission for Health Care20 deficiencies
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IDG, care planning, coordination of services (42 CFR 418.56)
“Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536”
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Core services (42 CFR 418.64)
“Upon personnel record review, 1 of 12 (Personnel #8) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Medical social services Personnel #8: The Social Worker is paid as contracted 1099 employee. Agency/MSW confirmed this personnel is not on payroll for withholdings to be directly deducted and paid to the government.”
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Organizational environment (42 CFR 418.100)
“Condition of Participation: Organization and Administration of Services.”
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Content of comprehensive assessment (42 CFR 418.54(c)(6))
The inspectors’ words, 119 words
“Upon patient record review, 7 of 8 (Patients #1, #2, #3, #4, #5, #6, #7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: The patient had Morphine, Ativan, Ondansetron, Albuterol, and Oxygen. These medications were not included on the medication profile. Patients #2, #3, #4, #5, #6, #7: The record reflected these patients had oxygen. Oxygen was not included on the medication profile.”
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Content of comprehensive assessment (42 CFR 418.54(c)(7))
The inspectors’ words, 107 words
“Upon patient record review, 1 of 8 (Patient #6) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #6: The Initial Bereavement Risk Assessment was completed on 4/26/23. This assessment was completed after patient died (4/11/23) and not within 5 days of hospice start of care.”
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Content of plan of care (42 CFR 418.56(c)(2))
The inspectors’ words, 210 words
“Upon patient record review, 4 of 8 (Patients #3, #4, #5, #6) did not have evidence the plan of care (POC) must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3: The MSW visit frequency indicated PRN and recertification. The SC frequency was listed as 1X then PRN. These frequencies did not identify number of PRN’s for the MSW or SC on the POC. Patient #4: The MSW and SC visit frequency indicated 1X then PRN. These frequencies did not identify number of PRN’s for the MSW or SC on the POC. Patient #5: The SC frequency indicated 1X then PRN. This frequency did not identify number of PRN’s on the POC. Patient #6: The MSW and SC visit frequency indicated 1X then PRN. These frequencies did not identify number of PRN’s for the MSW or SC on the POC.”
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Content of plan of care (42 CFR 418.56(c)(4))
“Upon patient record review, 1 of 8 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: This patient had Morphine, Ativan, Ondansetron and Albuterol Solution at the Board and Care. These medications were not included on the plan of care.”
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Content of plan of care (42 CFR 418.56(c)(5))
“Upon patient record review, 4 of 8 (Patients #1, #2, #3, #5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patients #1, #2, #3, #5: The record reflected that these patients had an albuterol inhalation solution orders on the plan of care. The DME Nebulizer machine was not included on their individualized plan of care.”
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Review of the plan of care (42 CFR 418.56(d))
The inspectors’ words, 97 words
“Upon patient record review, 2 of 8 (Patient #1,#8) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient #1: IDG met on Friday 6/28/24 and Friday 7/26/24. There was no evidence the IDG met on Friday 7/12/24 to review the plan of care. Patient #8: IDG met on Friday 6/28/24 and Friday 7/26/24. There was no evidence the IDG met on Friday 7/12/24 to review the plan of care.”
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Coordination of services (42 CFR 418.56(e)(2))
“Upon patient record review, 1 of 8 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care (POC). Patient #6: The POC listed MSW visit frequency of 1 X per week. The MSW had visited 1X monthly, not weekly.”
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Program data (42 CFR 418.58(b)(3))
“Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.”
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Executive responsibilities (42 CFR 418.58(e)(1))
“Upon observation, there was no evidence of involvement of the governing body (GB) and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program in GB meeting minutes regarding Annual Summary of QAPI in binders. There are annual PIP’s only.”
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Counseling services (42 CFR 418.64(d)(1))
The inspectors’ words, 147 words
“Upon patient record review, 4 of 8 (Patients #2, #3, #4, #8) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patients #2, #3, #4, #8: The bereavement care plan did not contain assigned interventions, tasks and frequencies to meet the needs of the bereaved. There was evidence of letters sent, but no individualized care plan approved/meeting by IDG after patient passing.”
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Hospice aide assignments and duties (42 CFR 418.76(g)(1))
The inspectors’ words, 174 words
“Upon patient record review, 2 of 8 (Patient #1, #5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The Aide has been visiting 2X’s per week from 4/29/24. This frequency is not indicated on POC or listed as a supplemental order. Patient #5: The Aide had been visiting 2X’s per week. This frequency is not indicated on POC or listed as a supplemental order.”
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Hospice aide assignments and duties (42 CFR 418.76(g)(2))
“Upon patient record review 2 of 8 (Patients #3, #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #3: The POC listed aide visit frequency of 2 X’s per week (6/12/24). For Benefit Week there was only 1 visit on 6/13/24. Patient #4: The POC listed aide visit frequency of 2 X’s per week (6/12/24). For Benefit Week there was only 1 visit on 6/13/24.”
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Governing body and administrator (42 CFR 418.100(b))
The inspectors’ words, 91 words
“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The agency was not providing core services as evidenced by the social worker was a contracted 1099 employee and not on the agency payroll for withholdings. In addition, the agency did not have involvement of the governing body in the QAPI program as there was no evidence of approval of the frequency and detail of data collection and annual summary of QAPI.”
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Medical director contract (42 CFR 418.102(a))
“Upon contract review, 1 of 4 (alternate medical director contract) did not have evidence of a contract to fulfill the role of alternate medical director. The agency was unable to locate the alternate medical director contract.”
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Content (42 CFR 418.104(a)(2))
“Upon patient record review, 4 of 8 (Patients #1, #4, #5, #7) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patents #1 and #5: The election statement did not include BFCC-QIO contact information or hospice agency name on the form. Patent #4: The election statement did not include effective date for hospice services to start. Patient #7: The election statement indicated effective date of 12/6/22. The hospice services began on 12/7/22.”
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Discharge or transfer of care (42 CFR 418.104(e)(3))
“Upon patient record review, 2 of 8 (Patients #5, #6) did not have evidence that the discharge summary includes all required information. Patients #5, #6: Did not have evidence that the discharge summary included patients plan of care as required.”
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Criminal background checks (42 CFR 418.114(d)(2))
“Upon personnel record review, 1 of 12 (Personnel # 9) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #9: The Criminal Background check for the Aide had a misspelled name with an extra letter “c” added; this does not match employee name.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Oct 28, 2024 | Initial follow-up inspection by the Accreditation Commission for Health Care | No deficiencies cited |
| Sep 11, 2024 | Initial inspection by the Accreditation Commission for Health Care | 20 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Jun 2, 2021.
- Ownership: for-profit.
- Cited at 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. in the last three years: it didn’t meet a whole condition of Medicare’s rules.
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?
- CMS hasn’t published nursing time from Medicare claims for this hospice.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 100% at home.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
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 gives no Hospice Care Index for this hospice.
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
How does it compare nearby?
- Of the 134 hospices CMS’s data show serving patients in ZIP code 91789, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 8; this one had 20.
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 |
|---|---|
| St. Mary’s Hospice, Inc. | 38 |
| Elysium Hospice Care, Inc. | 1 |
| Monarch Hospice Care, Inc. | 0 |
| California Comfort Care, LLC This hospice | 20 |
| Kaiser Foundation Hospital Hospice Program | 3 |
| Providence at Home With Compassus Hospice Care La County | 5 |
| Vnacare | 9 |
| Hospice of Presbyterian | 8 |
| Vitas Healthcare Corp | 18 |
| Torrance Memorial Hospice | 4 |
| Community Care Hospice | 11 |
| Bristol Hospice- Greater Los Angeles | 8 |
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).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
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.