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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 07/10/2021
Date Signed: 07/10/2021 07:17:10 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2021 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20210710114608
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:
07/10/2021
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Susie Jumawan; AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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1) Facility is in disrepair.
2) Facility has roaches.
3) COVID Protocols not followed: Screening and mask wearing.
INVESTIGATION FINDINGS:
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On 7/10/21 at 1:45 PM, Licensing Program Analyst (LPA) Cheng, Singh, Johnson, and Licensing Program Manager (LPM) Munoz conducted an unannounced complaint investigations visit regarding the above allegations. LPAs and LPM met with Administrator Susie Jumawan and explained the reason for the visit. Prior to initiating the visit, LPAs and LPM 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. LPAs and LPM ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask and gloves.

Continuation on LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 25-AS-20210710114608
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/10/2021
NARRATIVE
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** This is an amended version of the original report delivered on 7/10/2021 and replaces the original report.**

1) Facility is in disrepair.

Based on statements and service reports obtained on 7/9/2021, facility air conditioning unit is not working properly. Facility service reports indicate that the air conditioning blower for the backside of the facility is not working properly and requires a replacement. The service report also indicates that the air conditioning unit in the kitchen is requires a recharge of "freon". LPA Johnson and LPM Munoz observed that only 4 air vents in the facility was operational.

2) Facility has roaches.

Based on observations from facility visit on 7/9/2021, LPAs Cheng and Singh observed cockroaches in resident room #17 and #16. R1 in room #16 confirmed that there were cockroaches in the resident bathrooms. LPA Singh observed cockroaches in facility kitchen areas on 7/9/2021.

3) COVID Protocols not followed: Screening and mask wearing.

Based on statements obtained and document reviewed on 7/9/2021, LPAs Cheng and Singh observed that facility was not documenting staff and visitor responses to symptom screening. Facility documents show that the last documented symptom screening was dated in 5/2021. Facility was cited for failure to follow COVID protocols during LPAs Cheng and Singh visit on 7/9/2021; CCR 87468.1(a)(2).

Based on LPAs and LPM information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of report was provided along with appeal rights.

SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20210710114608
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operations (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Licensee agreeed to submit to LPA an action plan regarding fixing facility's air conditioner unit and cockroach infestation via e-mail by POC date.
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Based on observation and service reports obtained, Licensee did not keep the facility air conditioner in good repair and did not keep facility free of cockroaches which poses an immediate health and safety risk for all residents in care.
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LPA will review facility's POC and follow-up with Licensee to ensure their action plans are being enforced.
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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: 07/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2021
LIC9099 (FAS) - (06/04)
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