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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 07/17/2021
Date Signed: 07/17/2021 04:34:08 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:
07/17/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Licensee Brian Jumawan
Manager Maria Medrano
TIME COMPLETED:
04:45 PM
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On 7/17/21 at 3:30 PM, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with Licensee Brian Jumawan 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 7/17/21 at 3:36 PM, LPA Avila observed the following temperatures in their area. Facility left hallway entrance measured at 76.5 degrees Fahrenheit, resident room #24 measured 77 degrees Fahrenheit, right hallway entrance measured 78 degrees Fahrenheit, room #6 measured 85 degrees Fahrenheit and living room measured 77.5 degrees Fahrenheit. Left hallway liquid thermometer measured at 80 degrees Fahrenheit, front hallway liquid thermometer measured at 75 degrees Fahrenheit, and right hallway thermometer measured at 74 degrees Fahrenheit. Residents did not express any concerns.

Licensee set up portable AC units and Fans in the hallway that tempt warmer. Licensee set up seating in the left hall for individuals to sit. At time of visit HVAC tech arrived and began working on the unit..

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: 07/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2021
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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