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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 07/16/2021
Date Signed: 07/16/2021 04:53:55 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:
07/16/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Maria Medrano; Facility ManagerTIME COMPLETED:
05:00 PM
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On 7/16/2021 at 4:30 PM, Licensing Program Analyst (LPA) Cheng was providing facility a copy of their report for his visit on 7/16/2021 between 3PM - 4:30PM and observed that LPA Cheng had inputted the incorrect date on the report. LPA reviewed previous licensing reports from 7/13/21 to 7/16/21 and observed that all dates were incorrectly given. Licensing reports from the morning of 7/13/21 to morning of 7/16/21 was amended to correct the dates originally given on the report. All copies of the amended reports were signed by Facility Manage Maria Medrano and all amended copies were provided to facility.

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

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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