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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 07/11/2021
Date Signed: 07/11/2021 05:57:44 PM

COMPREHENSIVE INSPECTION
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:
07/11/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Susie Jumawan; AdministratorTIME COMPLETED:
06:00 PM
NARRATIVE
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On 7/11/21 at 12:30 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Annual Continuation visit from the Required 1-year inspection on 7/10/2021. LPA met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPA 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves.

The purpose of this visit was issue the remaining citations that were not issued on 7/10/2021 and input remaining resident document reviews onto form LIC 858.

Upon entry of remaining resident records into form LIC 858, LPA discovered six residents to be having or missing required resident records. CCR 87506(a) will be cited for facility failing to maintain a complete and current resident records.

CCR 87303(a) was previously cited on 7/10/2021 regarding facility not being safe, clean, and in good repair. Facility will be advised to resolve the issues of mold, the hole in the washing room wall, broken dishwasher, cracked flooring, and odor in resident room #17. LPA will follow-up with facility to verify that all issues noted above has been resolved.

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

DATE: 07/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2021
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 10
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: 07/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2021
Section Cited

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87555 General Food Service Requirements (b)(8) All food shall be of good quality. This requirement was not met as evidenced by:
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Based on observation, Licensee did not to maintain food of good quality, rotten food found, which poses an immediate health and safety risk to all residents in care.
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Licensee also agreed to conduct an in-service training regarding CCR 87555 - General Food Service Requirements.
Type A
07/12/2021
Section Cited

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87555 General Food Service Requirements (b)(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement was not met as evidenced by:
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Based on observation, Licensee did not store cleaning materials separate from food supplies (found in ice chest) which poses an immediate health and safety risk to all residents in care.
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Licensee also agreed to conduct an in-service training regarding CCR 87555 - General Food Service Requirements.
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: 07/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2021
LIC809 (FAS) - (06/04)
Page: 2 of 10
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: 07/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2021
Section Cited

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87307 Personal Accommodations and Services (a)(3)(C) The use of common wash cloths and towels shall be prohibited. This requirement was not met as evidenced by:
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Based on observation, Licensee did not prevent the use of a shared common hand towel for 2 of 2 clients which poses an immediate health and safety risk for 2 of 2 residents in care.
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Type A
07/12/2021
Section Cited

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87705 Care of Person of Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, ...cleaning supplies and disinfectants. This requirement was not met as evidenced by:
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Based on observation, Licensee did not keep cleaning and disinfectants inaccessible to dementia residents in care which poses an immediate health and safety risk to residents in care.
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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: 07/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2021
LIC809 (FAS) - (06/04)
Page: 3 of 10
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: 07/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2021
Section Cited

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87465 Inciental Medical and Dental (a) The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Based on medication review, Licensee did not provide medication assistance for R4 (missing 11 pills) which poses an immediate health and safety risk to 1 of 1 resident in care.
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Licensee will contact LPA by 7/26/21 to verify that resident medication review has been audited and LPA will conduct a field visit to conduct a sample verification.
Type B
07/26/2021
Section Cited

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87555 General Food Service Requirements (b)(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). This requirement was not met as evidenced by:
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Based on observation, Licensee did not ensure that facility refrigerator and freezer have a thermometer which poses a potential health and safety risk to all residents in care.
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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: 07/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2021
LIC809 (FAS) - (06/04)
Page: 4 of 10
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: 07/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2021
Section Cited

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87555 General Food Service Requirements (b)(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidenced by:
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Based on observation, Licensee did not ensure that kitchen area was free of flies (observed fly strip trap hanging from ceiling) which poses a potential health and safety risk to all residents in care.
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Type B
07/26/2021
Section Cited

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87618 Oxygen Administrator - Gas and Liquid (b)(3)(B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement was not met as evidenced by:
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Based on observation, Licensee did not ensure that there were proper precaution signs for oxygen use in resident room #18 and #22 which poses a potential health and safety risks for all residents in care.
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Deficiency cleared during visit.
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: 07/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2021
LIC809 (FAS) - (06/04)
Page: 5 of 10
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: 07/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2021
Section Cited

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87307 Personal Accommodations and Services (a)(3) The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads...this requirement was not met as evidenced by:
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Based on observation, Licensee did not provide a mattress pad for residents in room #24 which poses a potential health and safety risk for 1 of 1 resident in care.
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Type B
07/26/2021
Section Cited

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87465 Incidental Medical and Dental (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. This requirement was not met as evidenced by:
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Based on resident medication reveiw, Licensee did not destroy left over medication and equipment for 1 of 1 resident (R2) which poses a potential health and safety risk to all residents in care.
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Licensee also agreed to conduct a training regarding CCR 87465, Incidental Medical and Dental, and submit training materials along with staff signatures to LPA by POC date.
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: 07/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2021
LIC809 (FAS) - (06/04)
Page: 6 of 10
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: 07/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2021
Section Cited

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87465 Incidental Medical and Dental (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

(A) The name of the resident for whom prescribed.

(B) The name of the prescribing physician.

(C) The drug name, strength and quantity.

(D) The date filled.

(E) The prescription number and the name of the issuing pharmacy.

(F) Instructions, if any, regarding control and custody of the medication.

this requirement was not met as evidenced by:
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Based on resident medication review, Licensee did not completely fill out 1 of 1 resident's (R1) medication centrally stored medication log which poses a potential health and safety risk for 1 of 1 resident in care.
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Licensee will contact LPA by 7/26/21 to verify that resident medication review has been audited and LPA will conduct a field visit to conduct a sample verification.
Type B
07/26/2021
Section Cited

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87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement was not met as evidenced:
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Based on records review, Licensee did not maintain Continuing Education Units (4 of 4 staff) and Orientation completion verification (3 of 4 staff) which poses a potential health and safety risk for all residents in care.
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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: 07/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2021
LIC809 (FAS) - (06/04)
Page: 7 of 10
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: 07/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2021
Section Cited

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87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement was not met as evidenced by:
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Based on staff records review, Licensee did not ensure that 1 of 1 staff (S3) obtain a complete TB test which poses a potential health and safety risk to all residents in care.
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Type B
07/26/2021
Section Cited

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87411 Personnel Requirements - General (c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by:
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Based on staff records review, Licensee did not ensure that 1 of 1 resident (S1) maintain an active first aid/CPR certificate which poses a potential health and safety risk to all residents in care.
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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: 07/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2021
LIC809 (FAS) - (06/04)
Page: 8 of 10
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: 07/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2021
Section Cited

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87212 Emergency Disaster Plan (a) Each facility shall have a disaster and mass casualty plan of action. This requirement was not met as evidenced by:
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Based on facility records review, Licensee did not maintain a complete and up-to-date Emergency Disaster Plan (LIC 610E) which poses a potential health and safety risk to all residents in care.
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Type B
07/26/2021
Section Cited

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...this requirement was not met as evidenced by:
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Based on resident records review, License did not maintain a complete and current records for 6 of 6 residents which poses a potential health and safety risk for 6 of 6 residents in care.
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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: 07/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2021
LIC809 (FAS) - (06/04)
Page: 9 of 10
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: 07/11/2021
NARRATIVE
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CCR 87468.1(a)(2) was previously cited on 7/9/2021 regarding facility's failure to follow facility COVID-19 screening protocols. Facility will be advised to maintain a sufficient supply of toilet paper for residents' shared bathroom in resident room #18.

All remaining deficiencies observed on 7/10/2021 but were not cited on that day are now cited on LIC 809D on today's Case Management Annual Continuation visit.

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

DATE: 07/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2021
LIC809 (FAS) - (06/04)
Page: 10 of 10