585002798-3-9-2022-25-AS-KHOS-CCLJYE-20220317072749

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 03/09/2022
Date Signed: 03/09/2022 12:23:37 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
09/27/2021 and conducted by Evaluator Mai Thao

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210927162256

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:	03/09/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Maria Medrano, Facility Manager and Susie Jumawan, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident being hit by another resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to deliver findings for the above allegation. Prior to 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask. In addition, Staff screened LPA prior to entering the facility.

During today’s visit, LPA delivered findings.

(Continue 9099-C….)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

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-20210927162256

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: 03/09/2022

NARRATIVE

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Resident being hit by another resident
It was alleged that Resident 1 (R1) was hit by Resident 4 (R4). R4 stated in interviews that R4 have never hit any resident before. Resident 2 (R2) stated in interviews that R2 saw R4 hit R1's arm. R1 stated that R4 slap R1 on the arm. Resident 3 (R3), Resident 5 (R5) and Resident 6 (R6) stated in interviews that they did not see R4 hit R1. R5 stated that there are a lot of arguments but never anything physical. Staff who were interviewed stated that R1 and R4 does not get along and argue with each other, but have never seen them hit each other. Staff stated that when there are any resident arguing, staff intervene immediately. Staff 1 (S1) stated in interview that S1 had to separate R1 and R4 once because they were arguing over a chair and the Television. Staff stated that staff separated the 2 residents, but did not observe hitting. Administrator stated that R1 and R4 have not gotten into any physical altercation or hit each other before. Administrator stated that residents would sometimes argue over certain things, but staff intervene quickly. 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.

Per California Code of Regulations, Title 22, No citations were issued.

An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

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