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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 12:21:37 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-20211214090123
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:
10:45 AM
MET WITH:Maria Medrano, Facility Manager and Susie Jumawan, Administrator TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff treat residents differently
Staff do not provide supplies necessary for personal care and maintenance of adequate hygiene practice
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to deliver findings for the above allegations. 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-20211214090123
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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Staff treat residents differently
Residents who were interviewed, stated that staff do not treat residents differently. Residents stated in interview that the staff does their best to meet their needs. Staff stated in interviews that staff treats all residents equally. Administrator also confirms in interviews. This agency has investigated the complaint alleging Staff treat residents differently . 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.

Staff do not provide supplies necessary for personal care and maintenance of adequate hygiene practice
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 Staff do not provide supplies necessary for personal care and maintenance of adequate hygiene practice. 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