<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 07/28/2020
Date Signed: 07/28/2020 02:21:36 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 COHASETT 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: 38DATE:
07/28/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Susie Jumawan, Licensee/Administrator and Maria Medrano, Facility ManagerTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mai Thao conducted a scheduled case management televisit in regards to a Health and Safety check. LPA met with Licensee/Administrator, Susie Jumawan, and Facility Manager, Maria Medrano. A physical visit was not conducted due to COVID-19. LPA explained purpose of visit and toured the facility inside and out, but not limited to facility kitchen, living room, dining room, outside area, bathrooms, facility office and resident rooms.

Hot water temperature in the kitchen measured at 109.6 degrees F. Facility has a 7-day non-perishable and 2-day perishable supply of food. Smoke and carbon monoxide detector were observed to be operational. Outside area is free of obstruction and no bodies of water present. Medication are centrally stored in locked medication cart in the office area. All hazardous and dangerous objects/items are kept locked and inaccessible to clients.

Records and medication audit was not completed due to visit being completed via tele-visit.

During the tele-visit, LPA, Licensee and Facility Manager discussed some COVID-19 precautions measures that the facility have in place and importance of having Personal Protective Equipment (PPE). LPA advised that facility staff treat the facility like a public area and wear masks.

No deficiency was cited. Exit interview was conducted and a copy of this report was sent to Licensee to signed and return to put on file.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (530) 895-5805
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2020
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 1