Comfort Hospice, Inc.
San Marino, California · CCN 921574
1635 Chelsea Road
17 federal deficiencies across 2 surveys, November 17, 2022 to November 6, 2025.
Excludes the inspector’s preamble, which is not a finding
Federal surveys with at least one deficiency
Findings against a Condition of Participation — a compliance grade, not a measure of harm
What level the findings sit at
- Condition-level211.8%
- The agency was out of compliance with a federal Condition of Participation — a requirement it must meet to take part in Medicare at all.
- Standard-level1588.2%
- A requirement within a Condition of Participation. The Condition itself was not cited.
These are compliance grades, not harm grades: how deep in the regulation a finding sits, not whether anyone was harmed.
Who conducted the surveys
TJC.
Federal surveys are carried out by the state agency or a CMS-approved accrediting organisation.
Most-cited requirements
- L0530Content of Comprehensive Assessment1
- L0532Content of Comprehensive Assessment1
- L0545Content of Plan of Care1
- L0547Content of Plan of Care1
- L0548Content of Plan of Care1
Survey record
Condition-level
| Survey | Type | Deficiencies | Condition-level |
|---|---|---|---|
| Nov 6, 2025 | Reaccreditation | 5 | — |
| Nov 17, 2022 | Reaccreditation | 12 | 2 |
In the inspector’s words
The complete written findings for this hospice, in the inspector’s own words.
Hospice findings published by CMS on QCOR, covering surveys from November 17, 2022 to November 6, 2025. The inspectors’ written findings come from a single CMS survey-report extract.
Federal survey findings only. State licensure findings for hospices are not shown.
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