585002798-3-9-2022-25-AS-KHOS-CCTKWR-20220324081623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 03/09/2022
Date Signed: 03/09/2022 12:20:37 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
12/14/2021 and conducted by Evaluator Mai Thao

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211214084617

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:	10:00 AM
MET WITH:	Maria Medrano, Facility Manager and Susie Jumawan, Administrator		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Resident is not provided with hygiene items of general use

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….)

Unfounded

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-20211214084617

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 is not provided with hygiene items of general use
On 2/11/2022, Licensing Program Analyst (LPA) Mai Thao conducted a facility toured with Facility Manager (FM) and observed the facility to have sufficient hygiene products available for residents in care. Residents stated in interviews that they have their own hygiene products and when they run out, the facility always have it available. Staff stated in interviews that the facility always have hygiene products available along with other items for the residents in care. Administrator also confirms in interviews that the facility have hygiene products available for residents to use. This agency has investigated the complaint alleging Resident is not provided with hygiene items of general use. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

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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