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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 06/03/2020
Date Signed: 06/07/2020 08:23:50 AM



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
02/10/2020 and conducted by Evaluator Misty Valencia
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20200210120423
FACILITY NAME:COMFORT HAVEN FOR THE ELDERLYFACILITY NUMBER:
585002798
ADMINISTRATOR:JUMAWAN, SUSIEFACILITY TYPE:
740
ADDRESS:125 E TENTH STREETTELEPHONE:
(530) 777-9698
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:48CENSUS: 41DATE:
06/03/2020
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Susie Jumawan, Administrator/Licensee, Brian Jumawan, Licensee and Maria Medrano, Manager.TIME COMPLETED:
09:31 AM
ALLEGATION(S):
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Lack of supervision resulted in the resident sustaining multiple injuries requiring hospitalization.
Staff did not implement a care plan to address the resident's tendency to wander.
Staff did not implement auditory devices on exit doors, for residents who wander.
Staff did not include all relavant details concerning the resident in the incident report.
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 as discribed above and deliver the findings, with Maria Medrano, Manager.



Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 25-AS-20200210120423
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: 06/03/2020
NARRATIVE
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R1 eloped from the facility on 04/04/2020 sustaining lacerations, bruising, acute nasal bone fractures and an intertrochanteric fi-achire (specific type of hip fracture) involving the right femur. Facility records state, at the time of admission to the facility (09/09/2018), R1’s Physicians Report and Preplacement Appraisal Information (LIC 603) document that R1 has been diagnosed with dementia. The LIC 603 lists that there is a needed special observation/night supervision (due to confusion, forgetfulness, and wandering). Sutter Home Health Records from January-March 2019 document R1 was homebound due to dementia and being a fall risk. These records also documented that R1 required supervision or touching assistance with mobility and that the facility staff were instructed and had knowledge to assist R1 with transfer and ambulation due to fall risk.

Facility Administrator, Maria Medrano completed an Unusual Incident Report (UIR) detailing the events of 04/04/2019. Medrano reported on the UIR that R1 was last seen by staff at approximately 0530 hours in the TV room and R1 was discovered to be missing at 0600 hours by Staff (S1). Facility does not have auditory devices on exit doors. According to Marysville Police Department (MPD) records, Medrano called MPD on 04/04/2020 at 0626 hours and reported R1 was last seen at 0515 hours. S1 estimated she discovered R1 missing at approximately 0615 hours., S1 admitted that R1 had a history of trying to leave the facility during the day and wandering at night. S1 stated she had previously found R1 missing from R1’s room and had located R1 asleep in other rooms. S1 reports that management were aware of R’1 behavior. Bi-County Ambulance was dispatched at 0520 hours to 13th/C Street, Marysville. R1 was located down a 5-foot rocky embankment near the edge of Ellis Lake. R1 told paramedics that he did not know how long he had been there. (The location R1 was found is approximately 0.7 miles from the facility, (with an estimated average walk time of 15 minutes) Emergency Department Triage Noted that R1 was "down up to 2.5 hours possibly. Found lying on right side by passerby and EMS was called estimating that R1 left the facility sometime after 0300 hours." Based on the established timeline, R1 eloped from the facility sometime before 0500 hours. Staff were not aware R1 was missing until approximately 0615 hours. Staff did not implement care plan to address wandering concerning R1. Based on this information and investigation findings conducted by the department, the allegations are substantiated.
Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. As a result of R1 sustaining serious bodily injury, the violation warrants a civil penalty assessment. At this time the civil penalty assessment is under review and a civil penalty determination is pending. The LPA will return at a future date to assess the penalty. Failure to correct the deficiencies may also result in civil penalties. Appeal rights were provided and exit interview conducted.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 25-AS-20200210120423
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2020
Section Cited
CCR
87705(c)(4)
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87705(c)(4) Care of Persons with Dementia. (c)Licensees who accept and retain residents with dementia...(4) There is an adequate number of direct care staff to support each resident’s physical...
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Licensee agrees to immediately increase staffing levels to meet the residents needs at the facility to avoid residents being left alone. Licensee to send in LIC 500 showing increased staffing levels by 06/15/2020
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This requirement is not met as evidenced by: based on observation/interview/record review the licensee did not insure that more than one staff was on shift when a resident eloped resulting in resident’s injuries.
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Type A
06/15/2020
Section Cited
CCR
87761(C)(1)
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87761(C)(1) an immediate penalty of $500.00 shall be assessed for any of the following:(1) Sickness, injury or death of a client has occurred as a result of the deficiency.
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Administrator will provide a written facility policy outlining elopement prevention. Policy to be received to CCL by 06/15/2020
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This requirement is not met as evidenced by: based on observation/interview/record review the licensee did not insure resident was unable to elope from the facility causing hospitalization.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 25-AS-20200210120423
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2020
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D)Each licensee shall furnish to the licensing agency such reports… (1) A written report shall be submitted to the licensing agency and to the person responsiible…(D)Any incident which threatens the...
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Administrator agrees to have an outside vendor complete Reporting Requirement training. Training to be scheduled by and completed by 06/15/2020.
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This requirement is not met as evidenced by: based on observation/interview/record review the licensee did not insure all information was included in the Unusual Incident report dated 04/04/20
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Type A
06/01/2020
Section Cited
CCR
87705(j)
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87705(j) Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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Licensee agrees to immediately install a new device so the auditory device is functioning. A written plan acknowledging that the device is working and will remain in working order will be sent to CCL by 06/15/2020
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This requirement is not met as evidenced by: based on observation/interview/record review the licensee did not ensure that any auditory devices in place when facility accepts dementia residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4