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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 03/09/2022
Date Signed: 03/09/2022 12:22:35 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
10/26/2021 and conducted by Evaluator Mai Thao
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20211026115647
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: 39DATE:
03/09/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Maria Medrano, Facility Manager and Susie Jumawan, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility is not allowing a medical assessment to be conducted on resident in a timely manner
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 OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (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)
Page: 1 of 2
Control Number 25-AS-20211026115647
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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Facility is not allowing a medical assessment to be conducted on resident in a timely manner

It was alleged that Licensee did not allow Resident 1 (R1) to get an updated medical assessment indicating a diagnosis of Dementia. R1 was admitted to the facility on 1/20/2021. LPA observed that facility have a medical assessment prior to R1 moving to the facility with a date of 11/06/2020. LPA observed that medical assessment indicated that R1 has dementia. LPA also observed an updated medical assessment completed on 12/30/2021 still indicating that R1 has a diagnosis of Dementia. Based on observations, interviews, and documented collected, Licensee ensured that a medical assessment was conducted timely. This agency has investigated the complaint alleging Facility is not allowing a medical assessment to be conducted on resident in a timely manner. 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 OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai ThaoTELEPHONE: (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)
Page: 2 of 2