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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 07/18/2021
Date Signed: 07/18/2021 09:51:50 AM

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: 39DATE:
07/18/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Med Tech Sandra Ramos
Manager Maria Medrano		TIME COMPLETED:
10:05 AM
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On 7/18/21 at 8:45 AM, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with facility staff Maria Cortez and manager Maria Medrano 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 staff 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: N95.

On 7/18/21 at 9:00 AM, LPA Avila observed the A/C to be operational. LPA received an e-mail from Licensee Brian Jumawan on 7/17/21 at 5:36PM stating the A/C was now working. LPA spoke with manager Maria Medrano and confirmed the HVAC system was working. LPA discussed Title 22 80088(a)(1) -A comfortable temperature for clients shall be maintained at all areas. The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C).

Maria stated they will continue to monitor the liquid thermometers and make adjustments as needed to ensure compliance.

Exit interview conducted and a copy of report was given.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2021
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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