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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 07/10/2021
Date Signed: 07/13/2021 12:31:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
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: 42DATE:
07/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Susie Jumawan; AdministratorTIME COMPLETED:
07:30 PM
NARRATIVE
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** This is an amended version of the original report delivered on 7/10/2021 and replaces the original report.**

On 7/10/21 at 1:30 PM, Licensing Program Analyst (LPA) Cheng, Singh, Johnson, and Licensing Program Manager (LPM) Munoz conducted an unannounced required 1-year inspection. LPAs and LPM met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPAs and LPM completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPAs and LPM ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves.

LPA Johnson and LPM Munoz toured the facility inside and out including but not limited to facility kitchen, dining area, hallways, outside area, resident bathrooms, resident rooms, and facility medication room.

On 7/10/21 at 1:45 PM, LPA Johnson and LPM Munoz observed the following issues in the facility kitchen. Facility refrigerator and freezer has no temperature gauge to display that the refrigerator is being kept at a temperature of 40 degrees Fahrenheit and freezers are being kept at 0 degrees Fahrenheit. LPA Johnson and LPM Munoz observed rotten food in the kitchen refrigerator and fly trap strips hanging from the ceiling by food storage and over dining tables. Cleaning materials were observed to be stored in the facility kitchen ice bucket located next to the food storage. Facility dishwasher was observed to be non-operational.
Continuation on LIC 809C.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COMFORT HAVEN FOR THE ELDERLY
FACILITY NUMBER: 585002798
VISIT DATE: 07/10/2021
NARRATIVE
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On 7/10/2021 at 2PM, LPA Johnson and LPM Munoz observed the facility hallway in front of the facility office to be cracked flooring and in disrepair.

On 7/10/2021 at 2:15 PM, LPA Johnson and LPM Munoz observed the following resident room issues. Resident room #18 smells of odor. Residents were sharing a common towel. Facility did not have toilet paper available in the resident bathroom. Resident's shared bathroom wall behind the toilet showed signs of mold. Resident bathroom has "Raid" pesticide accessible to residents in the shared bathroom. Resident utilizes an oxygen tank and resident room does not have any signs indicating oxygen usage. Resident in room #22 utilizes an oxygen tank and there are no oxygen signs posted. Resident in room #24 does not a mattress pad.

On 7/10/2021 at 2:40 PM, LPA Johnson and LPM Munoz observed a hole in the facility "wash room"/shower room.

On 7/10/2021 at 2:45 PM, LPA Johnson and LPM Munoz observed facility fire extinguishers to be last serviced in 2015. A civil penalty of $500 is issued for CCR 87203.

On 7/10/2021 at 2:50 PM, LPA Johnson reviewed 42 of 42 resident medications and their logs. LPA Johnson observed two of R1's medication to not have a start date. R2 has not been at the facility for at least six months and their medications have not been destroyed. R3 has medications that are not accounted for. R4's is missing physician discontinue order a medication.

On 7/10/2021 at 3PM, LPA Singh, Johnson, Cheng and LPM Munoz reviewed 42 resident files and staff files. LPAs observed that S1-S4 were missing continuing education units, S2-S4 were missing orientation verification documents, S3 does not have a compete TB test screening, and S1's first aid/CPR was expired.

Continuation on LIC 809C.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: COMFORT HAVEN FOR THE ELDERLY
FACILITY NUMBER: 585002798
VISIT DATE: 07/10/2021
NARRATIVE
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Due to time restraints, LPA Cheng will return at a later time to conduct an annual continuation to issue remaining citations and/or civil penalties.

Deficiencies cited today are issued on LIC 809D.

Exit interview conducted and a copy of report along with appeal rights were issues.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COMFORT HAVEN FOR THE ELDERLY
FACILITY NUMBER: 585002798
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2021
Section Cited

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by:
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Based on observation, Licensee did not maintain inspection service for one fire extinguisher, last inspected 2015, and have facility ansul system operational which poses an immediate health and safety risk to all residents in care.
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A civil penalty of $500 was assessed.

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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: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4