585002798-8-10-2022-25-AS-KHIA-CH6PJM-20220810112145

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 585002798
Report Date: 08/10/2022
Date Signed: 08/10/2022 11:22:56 AM

Document Has Been Signed on 08/10/2022 11:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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:	DATE:	08/10/2022
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Brian and Susie Jumawan		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An office meeting was held on 08/10/2022 at 10:00 AM on a Microsoft Teams Meeting video conferencing system review the stipulation adopted on 07/26/2022 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period. The following were in attendance: Regional Manager Alycia Berryman, Licensing Program Manager Troy Ordonez, and Licensing Program Analyst Kerry Hiratsuka. Representing the facility are Licensees Brian and Susie Jumawan, and Administrator/Manager Maria Medrano. Alycia Berryman discussed the purpose and elements of this type of meeting. The Stipulation was reviewed with Representatives, Administrators, and Licensees who expressed their understanding. Items discussed at the meeting included, but not limited to: Stipulation contents · Findings · Revocation of License -Stayed with Probation · Limitations and conditions · Future Application for License, Registration, Certification or Approval · Licensure, Certification or Approval; Application Denial, Tolling of Probationary Period · Completion of Probation · Maintenance and Operation · General Food Service Requirements · Staffing training and requirements · Basic Services/Incidental Medical care · Technical Support Program ·

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/10/2022

NARRATIVE

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*Discussed the licensee’s ability to seek an early termination of probation after two years
· Violation of Stipulation Term
· Monitoring Fee
· Department's Authority
· Waiver of Hearing Rights; Waiver of Appeal/Modification Rights/Waiver of Claims
· Severable terms
· Public Records
· Signatures
· Counterparts
· Effective Date: (07/26/2022)

The Licensees/Respondents/Representatives stated they would abide by the following:
· Abide by the contents/terms of the Stipulation (submit all documents timely)
· Operate the facility in substantial compliance with the regulations and statues governing the operation of a residential care facility for the elderly.

CCLD will do the following:
· Increase monitoring

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

COMMENTS -LICENSE
PROBATION PERIOD 07/26//2022 TO 07/26/2025 FACILITY LICENSED FOR 48 NON-AMBULATORY RESIDENTS, 06 OF WHOM MAY RECEIVE HOSPICE SERVICES.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC809 (FAS) - (06/04)

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