585002798-5-18-2022-25-AS-TORZ-CF22K6-20220602172726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 585002798
Report Date: 05/18/2022
Date Signed: 05/18/2022 03:39:25 PM

Unsubstantiated

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
03/15/2022 and conducted by Evaluator Mai Thao

COMPLAINT CONTROL NUMBER: 25-AS-20220315150255

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:	02:30 PM
MET WITH:	Susie Jumawan, Administrator		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Resident's room is not being properly cleaned
Resident's room has roaches

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....)

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)

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Control Number 25-AS-20220315150255

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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Resident's room is not being properly cleaned

On 3/16/2022, Licensing Program Analyst (LPA) Mai Thao and Staff 1 (S1) toured the facility inside and out. LPA and S1 inspected 7 resident rooms. LPA and S1 observed all 7 room to be cleaned and odorless. LPA did not observe any soiled linens or clothing in the rooms. Residents who were interviewed stated that their rooms are cleaned daily by staff. Resident stated that staff comes daily to take out the trash. Resident 1 (R1) stated that when staff are assisting resident with changing, staff takes out the dirty linens and trash immediately. R1 stated that staff does not leave it in the room. Resident 2 (R2) stated that R2’s roommate uses disposable briefs and sometimes it can cause some odor in the bathroom. R2 stated that staff immediately takes out the trash when R2 inform staff. R2 stated that staff comes by daily to take out the trash during rounds. 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's room has roaches

On 3/16/2022, LPA and S1 toured the facility inside and out. LPA and S1 inspected 7 resident rooms. LPA and staff did not observe any roaches in the rooms inspected. Resident stated in interviews that last year the facility has roaches, but now there aren’t any. Resident stated that the facility has a pest control out monthly to inspect the facility and spray the facility. R1 stated that residents are told by staff to not store food in the room to prevent the rooms from having any roaches. R1 stated that sometimes R1’s roommate has food in the room, but R1 have not seen any roaches in R1’s room. 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. 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)

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