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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 10/02/2026
Date Signed: 10/02/2026 03:52:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2026 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20260615180140
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: 37DATE:
10/02/2026
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Maria MedranoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not notify authorized representative of incident.
INVESTIGATION FINDINGS:
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On October 2 2026 Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 06-15-26. LPA Benson met with Administrator Maria Medrano and explained the purpose of the visit.

During the interview process two staff and five residents were interviewed. Documents were obtained to include staff list with telephone numbers, staff work schedules, client admission agreement, care plan, medical records and incident reports.

Continued on LIC9099-C, LIC9099-D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2026
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2026 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20260615180140

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: DATE:
10/02/2026
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Maria MedranoAdministrator Maria MedranoTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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2
3
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9
Staff do not answer the phone.
INVESTIGATION FINDINGS:
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13
On October 2 2026 Licensing Program Analyst (LPA) Sarah Benson arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 06-15-26. LPA Benson met with Administrator Maria Medrano and explained the purpose of the visit.

During the interview process two staff and five residents were interviewed. Documents were obtained to include staff list with telephone numbers, staff work schedules, client admission agreement, care plan, medical records and incident reports.

Continued on LIC9099-A, LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20260615180140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COMFORT HAVEN FOR THE ELDERLY
FACILITY NUMBER: 585002798
VISIT DATE: 10/02/2026
NARRATIVE
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Staff do not answer the phone.

Record review revealed the facility has one line for the facility and client use. LPA Benson phoned the facility June 23, 2026 at 2:30p.m. the call was answered after five rings by a staff member. LPA Benson phoned the facility on 6-24-26 and observed as message stating, the mailbox is full. LPA Benson phoned twice on 8-19-26 with no answer, only a message stating the mail box is full and therefore not enough room to leave a message. LPA Benson observed that the message didn’t have an mail box meeting message. LPA received a call back from staff inquiring about my missed call on 8-19-26. LPA informed staff that the message didn’t state what number I had called and the voice mail box was full.


Resident interviews revealed the facility has a phone, and two out of five residents have used the phone for private use. LPA observed most residents have private cell phones.
During staff interviews, Staff stated when we call social security or the bank it takes up to 45 minutes for one call.

The administrator stated the staff use their private phones for calls. The administrator stated the facility has an answering machine when the clients are using the phone. The Licensee stated we bought a new phone August 21 2026 with two lines. The Licensee stated we will educate the staff to erase voice messages every day to open space for voice mail. Staff stated we will make sure medication technician staff have new phone with them to answer incoming calls.

Although the phone has been busy with full voice mail not allowing family, friends and LPA to contact residents or leave a message. Regulations state all facilities shall have telephone service on the premises. It was observed the facility has a phone.




Unsubstantiated.
Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 59-AS-20260615180140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: COMFORT HAVEN FOR THE ELDERLY
FACILITY NUMBER: 585002798
VISIT DATE: 10/02/2026
NARRATIVE
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Staff did not notify authorized representative of incident.

During staff interviews, the administrator stated the Ombudsman called me and said there was a complaint that R1’s responsible party was not notified when R1 was sent to the hospital. The administrator stated R1 went to the hospital June 13 2026, and we didn’t notify the party responsible until notified by the Ombudsman. The administrator stated I was not working when the incident occurred. Administrator stated after the Ombudsman called, I notified the responsible party on June 19 2026. The administrator stated we have protocol for medical emergency procedures. The administrator stated I made a copy and texted as a reminder to staff to always remember to notify the responsible party in the future.


Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20260615180140
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORT HAVEN FOR THE ELDERLY
FACILITY NUMBER: 585002798
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2026
Section Cited
CCR
87468.1(a)(8)
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87468.1(a)(8) (personal rights notify representative.)
Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.

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The licensee will have a staff meeting concerning Medical
Emergency Procedures.
The licensee will notify LPA when complete.
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This requirement is not met as evidenced by: the residents representative was not informed when the resident was sent to the hospital.

Which poses an immediate health, safety or personal rights risk to persons in care.


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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5