585002798-8-10-2020-25-AS-RLBN-BSWMSU-20200828095231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 08/10/2020
Date Signed: 08/10/2020 01:26:57 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 COHASETT RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/03/2020 and conducted by Evaluator Mai Thao

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20200603101739

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: 39	DATE:	08/10/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Maria Medrano, Facility Manager		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Lack of supervision resulting in resident harassing other residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mai Thao conducted an unannounced complaint phone visit on today’s date and spoke with Maria Medrano, Facility Manager. LPA explained the reason a physical visit was not conducted was because of COVID-19. LPA explained purpose of visit is to deliver findings for the above allegation.

During today’s phone visit, LPA delivered findings.

(Continue 9099-C......)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (530) 895-5805
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20200603101739

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 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: COMFORT HAVEN FOR THE ELDERLY	FACILITY NUMBER: 585002798
	VISIT DATE: 08/10/2020

NARRATIVE

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It was alleged that due to lack of supervision, Resident 1 (R1) was harassed by Resident 2 (R2). During interviews, R1 stated that staff intervene quickly and that nothing happened. R1 stated that R1 thought that R2 was going to hit R1, but R2 did not. R2 was not able to comment about the incident. Majority of residents interviewed stated that residents do not harass each other. Staff stated in interviews that this was the first-time incident happened and they were trained to intervene quick during incidents. LPA observed in both R1 and R2 LIC 602 Physician Report and LIC 625 Appraisal/Needs and Services Plan that there was no documentation stating that both residents require one-on-one supervision. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

No citations were observed during this complaint investigation. An exit interview was conducted and a copy of this report was emailed to Maria Medrano, Facility Manager.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (530) 895-5805
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

LIC9099 (FAS) - (06/04)

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