585002798-5-18-2022-25-AS-TORZ-CEQU46-20220524151437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 05/18/2022
Date Signed: 05/18/2022 03:38:45 PM

Substantiated

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
12/31/2021 and conducted by Evaluator Mai Thao

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211231120313

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: 37	DATE:	05/18/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Susie Jumawan, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Llittle availability of fruits, vegetables, either no menu or menu is not followed;
No alarm system for people going in and out of the building;
No activities provided to residents;

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mai Thao and IB Investigator Melissa Bennett, arrived at the facility unannounced on 5/18/2022 to conduct a Complaint Investigation Visit with the above allegations and met with Susie Jumawan, Administrator. Prior to visit, LPA and IB Investigator 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 and IB Investigator ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask and surgical mask. In addition, Staff screened LPA and IB Investigator prior to entering the facility.

During today's visit, LPA and IB Investigator toured the facility and delivered findings.

(continue (9099-C....)

Substantiated

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: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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 11

Control Number 25-AS-20211231120313

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: 05/18/2022

NARRATIVE

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Little availability of fruits, vegetables, either no menu or menu is not followed

On 1/3/2022, Licensing Program Analyst (LPA) Donna Gurriere observed that the facility did not have any fresh or canned fruit or vegetables. On 2/11/2022, 3/9/2022, and 3/15/2022, LPA Mai Thao observed the facility to have fresh and canned fruit and vegetables available. Residents who were interviewed stated that the facility have it available for them. Staff 1 (S1), stated in interviews that S1 does an inventory check in the kitchen weekly. S1 stated that groceries are done on Tuesday or Wednesday. S1 stated that staff goes shopping throughout the week if something runs out. S1 stated that sometimes an item is out of stock when the grocery is being done and staff will go out another day to get it. Administrator stated that the facility has fresh and canned fruit and vegetables all the time at the facility. LPA Thao was provided the facility’s menu. Staff 2 (S2) stated in interviews that a menu is posted outside of the Kitchen Door daily. S2 stated that they have a resident who like to pull down papers on the wall. S2 stated that the kitchen staff write down on the white board outside the kitchen door as well. Administrator and S2 stated that sometimes the facility will improvise or make something else that is different on the menu. Administrator and S2 stated that this happens occasionally because sometimes the grocery store runs out of ingredients. Staff 4 (S4) stated in interviews that there has been time when the facility ran out of fresh fruit at the facility. S4 stated that S4 notified the Licensee when they are “getting low” or out of fresh fruit. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

(Continue 9099-C....)

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 11

Control Number 25-AS-20211231120313

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: 05/18/2022

NARRATIVE

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No alarm system for people going in and out of the building.

On 2/11/2022 and 3/9/2022, LPA arrived at the facility unannounced and observed that the front door auditory device was not on. S2 confirmed that the auditory system is not on. S2 stated in interviews that the auditory system is loud and some residents do not like it so the facility staff turns it off. S2 stated that the auditory system is only used if a resident has a wandering behavior and there aren’t any residents with a wandering behavior. Administrator and S2 confirmed that the facility currently has 3 residents with a diagnosis of Dementia. LPA observed that all 3 residents cannot leave the facility unassisted. In other words, 3 residents with a diagnosis of Dementia cannot leave the facility unassisted because exiting presents a hazard. S2 immediately turned on the auditory system while LPA was at the facility. On 3/15/2022, LPA arrived at the facility for different visit and the auditory device was turned on. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

No activities provided to residents;

Residents stated in interviews that the facility used to have activities, but no longer have anything for the residents to do. Staff 2 (S2) stated in interviews that the facility has not have any activity due to COVID-19. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

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: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 11

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
12/31/2021 and conducted by Evaluator Mai Thao

COMPLAINT CONTROL NUMBER: 25-AS-20211231120313

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: 37	DATE:	05/18/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Susie Jumawan, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Building has bugs
Resident transferred to a different facility with less than 1 week’s meds

INVESTIGATION FINDINGS:

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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: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 11

Control Number 25-AS-20211231120313

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: 05/18/2022

NARRATIVE

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Building has bugs;

On 2/11/2022 and 3/9/2022, Licensing Program Analyst (LPA) Mai Thao toured the facility and did not observe any bugs at the facility. Residents that were interviewed stated that they have not seen any bugs at the facility. Staff confirmed in interviews that the facility does not have any bugs. Administrator stated that the facility did have a bug issue, but no longer have it. Administrator stated that the facility currently has a new contract with a new pest control company. Administrator stated that the pest control company has been coming monthly to the facility. 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.

Resident transferred to a different facility with less than 1 week’s meds;

LPA observed on facility’s Centrally Stored Medication Log for Resident 1 (R1) that R1 was admitted to the facility on 12/12/2021, with 2-week supply of medication from Skilled Nursing Facility. Staff 2 (S2) and Staff 3 (S3) stated in interviews that the facility counted R1’s medication and there was only 2 weeks’ worth of supplies. S2 and S3 stated that R1 provided S3 information on R1’s doctor and pharmacy. S3 stated that S3 called to refill the medications on 12/13/2021. S3 stated that S3 remember calling to follow up and was told that the doctor cannot approve refills because R1 has not gone to the doctor for over a year. S3 stated in interviews that S3 immediately assisted R1 in choosing a local doctor so that R1 can get prescription refills. S3 stated that the facility was able to get 1 medication refilled and staff picked it up from the pharmacy. S3 stated that S3 is not sure if R1 went to the doctor or not because R1 moved out of the facility before the appointment. 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.

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.

No citations were observed during this visit. 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: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 11

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
12/31/2021 and conducted by Evaluator Mai Thao

COMPLAINT CONTROL NUMBER: 25-AS-20211231120313

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: 37	DATE:	05/18/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Susie Jumawan, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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No place for residents to access water for drinking;
Runned down building;
No evacuation plan posted;
Physician's Report not completed upon intake for resident;
Residents outside of the building with no supervision

INVESTIGATION FINDINGS:

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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: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 11

Control Number 25-AS-20211231120313

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: 05/18/2022

NARRATIVE

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No place for residents to access water for drinking;

Residents stated in interviews that when Residents are thirsty, they can find water to drink. Residents stated that they go to the kitchen and ask for some water to drink. Residents stated in interviews that staff always give them something to drink. Staff stated in interviews that staff offers water to residents throughout the day. Staff 2 (S2) stated that some residents buy their own sodas and juices to drink. S2 stated that the facility used to offer a water station by the activity room. S2 stated that the water station was moved because of COVID-19. S2 stated that some residents were sharing cups and the facility wanted to prevent the spread of COVID-19 and other things. Staff 1 (S1) stated in interviews that when passing medications, S1 gives residents water. S1 stated that if there are other residents around, S1 would offer them water as well. S1 stated that residents would ask S1 for water and S1 would give it to them. S1 stated that the facility goes around once per shift to give out water to all residents. S1 stated that some residents refused to drink water because they do not like going to the restroom. S1 and Staff 3 (S3) stated that they always encourage residents to drink water throughout the day. The Department found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Runned down building;

On 2/11/2022, Licensing Program Analyst (LPA) Mai Thao toured the facility inside and out with Staff 2 (S2). LPA and S2 observed the facility to be clean and odorless. LPA and S2 inspected 5 resident bedroom and did not observe anything broken. All 5 rooms were clean and odorless. LPA inspected the Kitchen, Dining room, Shower Room, 2 bathroom in the hallway, and big TV room. LPA did not observe anything broken. All rooms were observed to be clean and odorless. On 3/16/2022, LPA and S2 (S2) inspected 7 random resident room and did not observe anything broken. All 7 rooms were clean and odorless. This agency has investigated the complaint alleging Runned down building. The Department found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

(Continue 9099-C.....)

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

Page: 7 of 11

Control Number 25-AS-20211231120313

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: 05/18/2022

NARRATIVE

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No evacuation plan posted;

On 2/11/2022, Licensing Program Analyst (LPA) Mai Thao arrived to the facility and observed that the facility’s evacuation plan is posted outside of the medication room. Administrator and S2 stated in interviews that there is a resident who likes to tear down paper on the wall. Administrator stated that staff does their best to print another one and post it up as soon as they see that it was taken down. This agency has investigated the complaint alleging No Evacuation Plan Posted. The Department found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Physician's Report not completed upon intake for resident.

Licensee Brian Jumawan stated in interviews that Resident 1 (R1) was referred to the facility through a referral agency. Licensee stated that Licensee went to the Skilled Nursing Facility to conduct a Pre-Appraisal and Assessment for R1. LPA observed that a LIC 603 PREPLACEMENT APPRAISAL INFORMATION was completed on 12/9/2021. LPA observed that R1 has a LIC 602 PHYSICIAN’S REPORT on file that was completed on 12/8/2021. LPA observed on facility records that R1 was admitted to the facility on 12/12/2021. This agency has investigated the complaint alleging Physician's Report not completed upon intake for resident. The Department found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the

(Continue 9099-C....)

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

Page: 8 of 11

Control Number 25-AS-20211231120313

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: 05/18/2022

NARRATIVE

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Residents outside of the building with no supervision

Staff stated in interviews that currently, the facility does not have any resident who will leave the facility unassisted. Staff 2 (S2) stated in interviews that residents who cannot leave unassisted are always accompany by a staff. S2 stated that Resident 2 (R2) is outside of the facility because R2 can leave the facility unassisted. S2 stated that there are some residents who are allowed to leave unassisted if the resident check themselves out. S2 stated R2 likes to walk, so R2 is usually found walking around the block and being outside the front of the facility. R2 stated that R2 likes to walk daily, and it keeps R2 out of trouble. LPA reviewed R2’s Physician’s Report (LIC 602) and it indicated that R2 can leave the facility unassisted. This agency has investigated the complaint alleging Residents outside of the building with no supervision. The Department found that the allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

“This agency has investigated the complaint alleging:

- No place for residents to access water for drinking;
- Runned down building;
- No evacuation plan posted;
- Physician's Report not completed upon intake for resident;
- Residents outside of the building with no supervision

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. We have therefore dismissed this complaint.”

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

Page: 9 of 11

Control Number 25-AS-20211231120313

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/19/2022 Section Cited CCR 87555(b)(26)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to submit in a statement to Licensing stating how Licensee can ensure there is a minnumum of two days of perishable fruits and vegetables at the facility by 5/19/2022.
	8 9 10 11 12 13 14	Based on observations and interviews, Licensee did not ensure that there were at least 2 days of perishable foods at the facility, facility did not have fresh fruit. which poses an immediate health and safety or personal right risk to all residents in care.	8 9 10 11 12 13 14
Type A 05/19/2022 Section Cited CCR 87705(j)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to submit in a statement to Licensing stating how Licensee can ensure that the auditory device stays on at all times by 5/19/2022.
	8 9 10 11 12 13 14	Based on observations and interviews, Licesee did not ensure that auditory devices were on to monitor exits which poses an immediate health and safety or personal rights risk to residents with dementia in care.	8 9 10 11 12 13 14

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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

Page: 10 of 11

Control Number 25-AS-20211231120313

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/25/2022 Section Cited CCR 87219(a)	1 2 3 4 5 6 7	87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. Ths requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to submit in 3 months of activity calendar to Licensing by 5/25/2022.
	8 9 10 11 12 13 14	Based on interviews and observations, Licensee did not ensure that there are activities at the facility which poses a potential health and safety or personal right risks to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC9099 (FAS) - (06/04)

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