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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 09/14/2021
Date Signed: 09/14/2021 12:33:32 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 ELDERLYFACILITY NUMBER:
585002798
ADMINISTRATOR:JUMAWAN, SUSIEFACILITY TYPE:
740
ADDRESS:125 E TENTH STREETTELEPHONE:
(530) 777-9698
CITY:MARYSVILLESTATE: CAZIP CODE:
95901
CAPACITY:48CENSUS: 38DATE:
09/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Maria Medrano; House ManagerTIME COMPLETED:
12:45 PM
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On 9/14/21 at 11:15 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced Case Management Health and Safety Check as directed by the department. LPA met with facility 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 Administrator 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: surgical mask and gloves.

On 9/14/21 at 11:30 AM, LPA Cheng observed Community Care Licensing's notice, issued posted 9/3/21, posted on on a cork board near the front office entrance.

On 9/14/21 at 11:45 AM, LPA Cheng conducted interviews with R1-R6's. LPA Cheng was able to confirm that 4 of 6 residents received their notice from the facility. 2 of 6 residents are conserved and LPA was unable to reach conservator for confirmation of receiving the notice. A voicemail was left requesting for a call back for confirmation.

Based on observations and statements received, LPA Cheng observed no deficiencies.

Exit interview conducted and a copy of report was given.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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