585002798-9-2-2021-25-AS-PCHG-C6H3LC-20210902182032

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 09/02/2021
Date Signed: 09/02/2021 06:21:32 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 ELDERLY		FACILITY NUMBER:	585002798
ADMINISTRATOR:	JUMAWAN, SUSIE		FACILITY TYPE:	740
ADDRESS:	125 E TENTH STREET		TELEPHONE:	(530) 777-9698
CITY:	MARYSVILLE	STATE: CA	ZIP CODE:	95901
CAPACITY:	48	CENSUS: 38	DATE:	09/02/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	05:45 PM
MET WITH:	Maria Medrano; Facility Manager		TIME COMPLETED:	06:30 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	On 9/2/21 at 5:45 PM, Licensing Program Analyst (LPA) Pheej Cheng met with House Manager, Maria Medrano, of Comfort Haven for the Elderly, in Yuba City, California for a complaint visit to follow up on a substantiated allegation of lack of care and supervision and personal rights violations. House Manager Maria Medrano contacted Licensee Susie Jumawan via phone and had her on speaker phone during the visit. On June 3, 2020, the Department concluded a complaint investigation which alleged that a lack of supervision resulted in a resident sustaining multiple injuries. It was concluded that staff did not implement a care plan to address a resident’s tendencies to wander, that there were no auditory devices on exit doors, and that staff did not include all relevant details concerning a resident in an incident report. Interviews and documents gathered during the course of the investigation show that R1 had a history of wandering and elopement attempts. R1’s Physicians Report and Preplacement Appraisal Information form (LIC 603) lists that there is a need for special observation/night supervision of R1 due to confusion, forgetfulness, and wandering. Additional records from Sutter Home Health document that R1 has a dementia diagnosis and is a fall risk. Despite these indicators, R1 was able to successfully elope from the facility. The allegations were substantiated and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87705(c)(4) for Care of Persons with Dementia, CCR Title 22, § 87705(j) for Care of Persons with Dementia, CCR Title 22, § 87761(c)(1) for Penalties. Specifically, on April 4, 2019, the facility failed to provide appropriate supervision to a resident resulting in an elopement, fall, and subsequent broken bones, then failed to properly report the incident to the Department. Continuation on LIC 809C.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/02/2021

NARRATIVE

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During the investigation, staff interviews revealed that R1 had last been seen by staff at approximately 5:30 a.m. and it was at 6:00 a.m. that R1 was discovered to be missing. The local police department was called at 6:26 a.m. and staff reported last seeing R1 at 5:15 a.m. S1 confirmed the facility does not have auditory door alarms and R1 did have a history of wandering at night, sometimes being found sleeping in the rooms of other residents. S1 confirmed management was aware of R1’s behaviors. At 5:20 a.m., Emergency Medical Services was contacted by a bystander who found R1 fallen near Ellis Lake. R1 was transferred and admitted on April 4, 2019 to a general acute care hospital where and was diagnosed with acute nasal bone fractures and an intertrochanteric fi-achire hip fracture. According to the Mayo Clinic, “an intertrochanteric fi-achire hip fracture is a hip fracture that occurs in the region a little further down from the hip joint, in the portion of the upper femur that juts outward. The treatment for this type of broken bone can be internal repair using screws, partial hip replacement, or total hip replacement. A hip fracture is a serious injury and with complications it can be life threatening. A hip fracture can result in an inability to get up from a fall, an inability to walk, severe pain, inability to bare weight, bruising, swelling, a shorter limb on one side of the body, and an outward turning of the leg on the injured side.”

The Emergency Department at the hospital triage noted that R1 appeared to have been down up to 2.5 hours and R1 could have went missing any time after 3:00 a.m. on April 4, 2019. R1 was treated at the hospital in Marysville, California, and was discharged to a Post-Acute setting for rehabilitation.

Continuation on LIC 809C.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/02/2021

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Based on medical records, interviews and a facility record review, facility staff did not provide appropriate care for a resident with dementia on April 4, 2019 by not having an awake staff person supervising R1, not having an appropriate care plan to address R1’s wandering behaviors, and not having auditory door alarms to alert staff of a resident attempting to elope from the facility. Due of the lack of supervision by the facility, the R1 was able to elope from the facility without notice, walk approximately 0.7 miles to a nearby park, fallen on a rocky embankment near a lake, and obtained lacerations, bruising, acute nasal bone fractures, and an intertrochanteric fi-achire hip fracture involving the right femur that required hospitalization, which is a serious bodily injury .

At the time of the complaint visit on June 03, 2020, the issuance of a civil penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000.

A copy of the LIC 421D was given to House Manager Maria Medrano and originals were signed.

Exit interview conducted. Appeal Rights provided. A copy of the report issued. House Manger Maria Medrano's signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC809 (FAS) - (06/04)

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