585002798-5-13-2020-25-AS-RLBN-BPPNJT-20200517103048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 05/13/2020
Date Signed: 05/13/2020 04:30:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2020 and conducted by Evaluator Misty Valencia

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20200506161808

FACILITY NAME:	COMFORT HAVEN FOR THE ELDERLY		FACILITY NUMBER:	585002798
ADMINISTRATOR:	JUMAWAN, SUSIE		FACILITY TYPE:	740
ADDRESS:	125 E TENTH STREET		TELEPHONE:	(530) 777-9698
CITY:	MARYSVILLE	STATE: CA	ZIP CODE:	95901
CAPACITY:	48	CENSUS: 37	DATE:	05/13/2020
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Maria Medrano, Manager		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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-Staff did not give resident money from payee
-Staff yell at resident

INVESTIGATION FINDINGS:

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Misty Valencia, Licensing Program Analyst (LPA) contacted the facility via telephone to deliver findings for a complaint via telephone due to COVID-19 and pre-cautionary measures. LPA discussed the complaint regarding the following allegations; Personal Rights - Staff yelled at a resident and Financial Issues-Staff did not give resident money from payee with Maria Medrano, Manager.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20200506161808

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COMFORT HAVEN FOR THE ELDERLY	FACILITY NUMBER: 585002798
	VISIT DATE: 05/13/2020

NARRATIVE

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Personal Rights - Staff yelled at a resident
Staff yelled at a resident-UNSUBSTANTIATED. LPA interviewed 6 staff, Licensee, House Manager and Resident (R1). All report that they have never witness or heard anyone yelling at anyone in an angry tone. Sometimes staff must raise their voices for the residents to hear them due to hearing loss. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED.

Financial Issues-Staff did not give resident money from payee

Financial Issues-Staff did not give resident money from payee-UNSUBSTANTIATED. LPA interviewed 6 staff, Licensee, House Manager and Resident (R1). All staff report that they are not responsible for any monetary or property decisions or have access. Licensee was unable to cash check due to bank closures and R1 was upset because the expectation was for the check to be cashed as soon as possible. R1 did not understand why he did not get his money until Licensee explained to R1 banks were closed. Check was given back to R1 and cashed at a later time. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED.

There were no citations issued during today's visit.

An exit interview was conducted with Maria Medrano, Manager, via telephone and a copy of this report, dated May 13, 2020 was provided to via email and an electronic email read receipt confirms receiving this document.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty Valencia	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2020

LIC9099 (FAS) - (06/04)

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